Aar91 04 PDF

/ \
PB91-910404
.J$~ 3 :y ?$ia NTSB/AAR-9 l/04
u:
NATIONAL
TRANSPORTATION’
SAFETY
BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT

AVIANCA, THE AIRLINE OF COLUMBIA
BOEING 707=321B, HK 2016
FUEL EXHAUSTION
COVE NECK,NEWYORK
JANUARY 25, 1990
plr 5255B
The National Transportation Safety Board is an independent Federal agency
dedicated to promoting aviation, railroad, highway, marine, pipeline, and
hazardous materials safety. Established in 1967, the agency is mandated by the
Independent Safet Board Act of 1974 to investigate transportation accidents,
determine the prog able cause of accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government
agencies involved in transportation.
The Safety Board makes public its actions and decisions through accident reports,
safety studies, special investigation reports, safet recommendations, and statistical
reviews. Copies of these documents may be pureK ased from the National Technical
Information Service, 5285 Port Royal Road, Springfield, Virginia 22161. Details on
available publications may be obtained by contacting:
National Transportation Safety Board

Public Inquiries Section, RE-51
800 Independence Avenue, S.W.
Washington, D.C. 20594
(202)382-6735
NTSB/AAR-91/04 PB91-910404
NATIONAL TRANSPORTATION
SAFETY BOARD
WASHINGTON. D.C. 20594
AVIANCA, THE AIRLINE OF COLUMBIA

BOEING 707-321 B, HK 2016
FUEL EXHAUSTION
COVE NECK, NEW YORK
JANUARY 25,199O
ADOPTED: APRIL 30,199l

NOTATION: 52558
Abstract: This report explains the crash of an Avianca Airlines Boeing 707-321B in
Cove Neck, Long Island, New York, on Januar 25, 1990. The safety issues discussed
in the report are pilot responsibilities an J dispatch responsibilities regarding
planning, fuel requirements, and flight following during international fli hts; pilot-
to-controller communications; air traffic control flow control. rote 8 ures; and
flightcrew coordination and English language proficiency o P foreign crews.
Recommendations concerning these issues were addressed to the Federal Aviation
Administration and the Department0 Administrativo de Aeronautic0 Civil (DAAC),
Columbia.
1
CONTENTS
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... V
1. FACTUAL INFORMATION
1.1 History of Flight ............................................. 1
1.2 Injuries to Persons ...........................................
1.3 Damage to Airplane ............................................ ::
1.4 Other Damage ..................................................
1.5 Personnel Information ......................................... ii!
1.5.1 The Captain ................................................... 14
1.5.2 The First Officer .............................................
1.5.3 The Flight Engineer ........................................... :i
1.5.4 Cabin Crew ....................................................
1.5.5 The Flight Dispatcher ......................................... :i
1.5.6 Air Traffic Controller ........................................
1.6 Airplane Information ........................................... :7
1.6.1 General .......................................................
1.6.2 Flight Plan and Performance Information ....................... ;:
1.6.3 Fuel System ................................................... 27
1.7 Meteorological Information .................................... 29
1.8 Aids to Navigation ............................................ 31
1.9 Communications ................................................ 31
1.9.1 Flight Following, Dispatching, and En Route Services .......... 31
1.10 Aerodrome Information ......................................... 32
1.11 Flight Recorders .............................................. 33
1.12 Wreckage and Impact Information ............................... 33
1.13 Medical and Pathological Information .......................... 38
1.14 Fire .......................................................... 38
1.15 Survival Aspects .............................................. 39
1.15.1 Rescue ........................................................ 39
1.15.2 Location of Crew and Passengers in Relation to Injuries ....... 39
1.16 Tests and Research ............................................
1.17 Additional Information ......................................... t:
1.17.1 Airline Procedures ............................................ 42
1.17.2 Air Traffic Control Facilities and Procedures ................. 43
1.17.3 Traffic Management ............................................ 44
1.17.4 Expect Further Clearance (EFC) Times .......................... 46
1.17.5 Air Traffic Control of Emergencies ............................ 47
1.17.6 Regulations and Airline Policies on Weather and Fuel ........... 48
2. ANALYSIS
2.1 General ....................................................... 51
2.2 Flight Planning ...............................................
2.3 Communications--Flightcrew (CVR) .............................. :P
Flight Data Recorder (FDR) .................................... 59
22:: Communications--Controllers ................................... 60
Pilot and ATC Communications--General ......................... 63
i:; Flightcrew Performance--The ILS Approach ...................... 66
Central Flow Control Facility (CFCF)--Traffic Management ...... 68
E Survivability .................................................. 71
2:9.1 Emergency Response ............................................ 73
iii
CONCLUSIONS
i-1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3:2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5. APPENDIXES
Appendix A--Investigation and Hearing .........................
Appendix B--CVR Transcript .................................... ii:
Appendix C--FAA Traffic Management ............................ 152
Appendix D--ATC Transcript .................................... 162
Appendix E--Surface Weather Observations ...................... 276
Appendix F--Comments on Draft Report From the Administrative
Department of Civil Aeronautics, Colombia .................... 282
iv
1
On July 19, 1989, at approximately 2134 eastern standard time,

Avianca Airlines flight 052, a Boeing 707-321B with Colombian registration
HK 2016, crashed in a wooded residential area in Cove Neck, Long Island, New
York. AVA052 was a scheduled international passenger flight from Bogota,
Colombia, to John F. Kennedy International Airport, New York, with an
intermediate stop at Jose Maria Cordova Airport, near Medellin, Colombia. Of
the 158 persons aboard, 73 were fatally injured.
Because of poor weather conditions in the northeastern part of the

United States, the flightcrew was placed in holding three times by air
traffic control for a total of about 1 hour and 17 minutes. During the third
period of holding, the flightcrew reported that the airplane could not hold
longer than 5 minutes, that it was running out of fuel, and that it could
not reach its alternate airport, Boston-Logan International. Subsequently,
the flightcrew executed a missed approach to John F. Kennedy International
Airport. While trying to return to the airport, the airplane experienced a
loss of power to all four engines and crashed approximately 16 miles from the
airport.
The National Transportation Safety Board determines that the

probable cause of this accident was the failure of the flightcrew to
adequately manage the airplane's fuel load, and their failure to communicate
an emergency fuel situation to air traffic control before fuel exhaustion
occurred. Contributing to the accident was the flightcrew's failure to use
an airline operational control dispatch system to assist them during the
international flight into a high-density airport in poor weather. Also
contributing to the accident was inadequate traffic flow management by the
Federal Aviation Administration and the lack of standardized understandable
terminology for pilots and controllers for minimum and emergency fuel states.
The Safety Board also determines that windshear, crew fatigue and
stress were factors that led to the unsuccessful completion of the first
approach and thus contributed to the accident.
The safety issues raised in this report include:
1. Pilot responsibilities and dispatch responsibilities

regarding planning, fuel requirements, and flight
following during international flights.
2. Pilot to controller communications regarding the

terminology to be used to convey fuel status and the need
for special handling.
3. ATC flow control procedures and responsibilities to

accommodate aircraft with low fuel state.
4. Flightcrew coordination and English language proficiency

of foreign crews.
Recommendations concerning these issues were addressed to the
Federal Aviation Administration and the Director, Department0 Administrativo
de Aeronautic0 Civil (DAAC), Columbia.
vi
NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C. 20594
AVIANCA, THE AIRLINE OF COLOMBIA

BOEING 707-321B, HK 2016
FUEL EXHAUSTION
COVE NECK, NEW YORK
JANUARY 25, 1990
1. FACTUAL INFORMATION
1.1 History of the Flight
On Thursday, January 25, 1990, at approximately 2134 eastern

standard time,' Avianca Airlines flight 052 (AVA052), a Boeing 707-321B with
Colombian registration HK 2016, crashed in a wooded residential area in Cove
Neck, Long Island, New York. AVA052 was a scheduled international passenger
flight from Bogota, Colombia, to John F. Kennedy International Airport (JFK),
New York, with an intermediate stop at Jose Maria Cordova Airport, near
Medellin, Colombia. Of the 158 persons aboard, 73 were fatally injured.
The flight was operating under the regulations of Colombia, and was
certified to operate in the United States under the provisions of Title 14 of
the Code of Federal Regulations (CFR) Part 129.2
AVA052 departed Bogota International Airport at 1310, 5 minutes

ahead of schedule. The flight landed at Medellin at 1404, and was refueled
and prepared for departure to JFK. There was no flightcrew change at
Medellin. The cockpit crew consisted of a captain, a first officer, and a
flight engineer (second officer). AVA052 departed Medellin at 1508.
The flight plan for AVA052 was via an oceanic route over Bimini,
Bahama Is1 ands, and then northbound toward the East Coast of the United
States. The flight was cleared into U.S. airspace by Air Traffic Control
(ATC) via Atlantic route 7 to Dixon, North Carolina, jet airway 174 to
Norfolk, Virginia (ORF), direct to Sea Isle, New Jersey, and then via the
CAMRN TWO ARRIVAL to JFK, at flight level 370 (FL370).3
’U n l e s s otherwise indicated, all times shown are eastern standard

time, b a s e d u p o n t h e 24-hour c l o c k .
2 14 CFR Part 129 governs the operations of foreign air carriers and
foreign operators of United States-registered aircraft engaged in common carriage.
3 Flight Level is a level of constant atmospheric pressure related to a

reference datum of 29.92 inches of mercury. Each is stated in three digits
that represent hundreds of feet. For example, flight level 370 represents a
barometric altimeter indication of 37,000 feet.
2
AVA052 entered the airspace of Miami Air Route Traffic Control

Center (ARTCC) at approximately 1728 at FL350. While in Miami airspace, the
flight was given clearance to climb from FL350 to FL370, in the vicinity of
URSUS navigational intersection, and was level at that altitude by the time
it reached ADOOR intersection.
As the flight proceeded northward, it was placed in holding three

times by ATC. AVA052 was instructed to enter holding first over ORF. This
period of holding was from 1904 to 1923 (19 minutes). The flight was placed
in holding a second time at BOTON intersection, near Atlantic City, New
Jersey. This period of holding was from 1943 to 2012 (29 minutes). The
flight was placed in holding a third time at CAMRN intersection. CAMRN
intersection is 39 nautical miles south of JFK. This third period of
holding was from 2018 to 2047 (29 minutes).
Between the ORF and CAMRN intersections, AVA052 was cleared to

descend to several lower altitudes. The flight entered the holding pattern
at CAMRN, at 14,000 feet mean sea level (msl). The flight was subsequently
descended to 11,000 feet while in the holding pattern. Figure 1 depicts the
track of AVA052 beginning at 2042:59.
At 2044:43, while holding at CAMRN, the New York (NY) ARTCC radar
controller advised AVA052 to expect further clearance (EFC) at 2105. The
flight had previously been issued EFC times of 2030 and 2039. The first
officer responded, ' . ..ah well I think we need priority we're passing
[unintelligible]." The evidence showed that the first officer was making all
AVA052's radio transmissions to U.S. controllers.4
The radar controller 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 at 2046:13, "ah we said Boston but ah it is ah full of
traffic I think." The controller said, ' . ..say again your alternate
4 Voice recordings are taken from the U.S. Air Traffic Control tape
recordings for Neu York Center, Neu York TRACON, and JFK Touer. Yhere
intracockpit conversations of the crewmembers are quoted herein, the
transcript was taken from the cockpit voice recorder (CVR) aboard the
flight. T h e C V R - r e c o r d e d t a p e c o v e r e d t h e p e r i o d f r o m 2053:09 t o 2133:34.
The recording r e v e a l e d t h a t t h e f i r s t o f f i c e r uas t h e o n l y c r e w m e m b e r w h o
spoke to ATC. The first officer received instructions from the ground
controllers in English and repeated the instructions in Spanish in the
cockpit. The cockpit creu speakers could not be heard on the area
microphone, e x c‘e p t when the crew received the Kennedy touer automatic
t e r m i n a l i n f o r m a t i o n s e r v i c e (ATIS) b r o a d c a s t , i n f o r m a t i o n Zulu, a t 2100:26.
The first officer was using a headset instead of the cockpit speakers to
receive the radio transmissions. A l l t h r e e o f t h e CVR’s r a d i o c h a n n e l s
contained identical signals, but it could not be determined whether the
captain or the second officer (flight engineer) were uearing headsets.
21
Feet)
J
72 (2.500 Feet) -
2
64
67 (3,200 Feet)
North
1 012345
III I I I I
Scale in N.M.
..* Recorded by FAA:

@I = Event Location :
l = Radar Return : AVA052 = Flt. 052 radio transmission
1 in. = 5 n.m. : CAMRN,R67 = Controller transmission
:
:
.=
.* Recorded by CVR:
.-* CAM 1, 2, 3 = Flightcrew comments
.Z
.** APPR,TWR = Controller transmissions
..* RDO 1, 2, 3 = Flightcrew radio transmissions
14 .=
BEGIN .=. 7 1 - Captain, 2 - First Officer, 3 - Flight Engineer

: B
1 ’
GPWS = Ground Proximity Warning System
2 ifLo
.s . (11,000 Feet)
3 .’
5 @b...*:*
Figure 1. --AVA052 flight reconstruction based on CVR, ATC radar

data, and ATC communications.
4
Time (H,M,S) Selected Diaglogue

1) 20,43,59 AVA052 - Thank you sir you have any estimates for us
2) 20,44,09 R67 - Avianca 052 heavy we just got off the line its indefinite hold at this time . . . hold at CAMRN .
3) 20,44,23 AVA052 - OK Avianca 052 heavy . . .
4) 20,44,43 R67 - Avianca 052 heavy expect further clearance time . . .
5) 20,44,50 AVA052 - Zero five two well I think we need priority we’re passing (unintelligible)
6) 20,44,58 R67 - Avianca 052 heavy Roger how long can you hold and what is your alternate
7) 20,45,03 AVA052 - OK stand by on that
8) 20,46,03 AVA052 - Yes sir we’ll be able to hold about five minutes thats all we can do
9) 20,48,08 R67 - Avianca 052 heavy Roger what is your alternate
10) 20,46,24 ’ Note - Now the handoff controller stops monitoring the frequency in order to phone
approach control and get a clearance for AVA052
11) 20,46,24 AVA052 - It is Boston but we can’t do it now we we will run out of fuel now.
12) 20,46,47 R67 - Avianca 052 heavy cleared to the Kennedy Airport via . . .
13) 20,46,57 AVA052 - Cleared to the Kennedy . . . Thank you
14) 20,47,04 R67 - Avianca 052 heavy contact New York approach . . .
14.1) 20,54,40 CAMRN - Avianca 052 turn right . . . I’m gonna have to spin you sir
14.2) 20,54,45 RD02 - Okay heading two two zero Avianca zero five two
15) 21,03,46 CAM 3- When we have - with with thousand pounds or less in any tank it is necessary to do --
16) 21,03,56 CAM3 - Then the go-around procedure is stating that the power be applied slowly and to avoid
rapid accelerations and to have a minimum of nose-up attitude
17) 21,09,29 CAM3 - They already know that we are in bad condition
18) 21,09,38 CAM2 - They are giving us priority
19) 21,11,07 APPR - Avianca 052 heavy you are one five miles from outer marker maintain two
thousand . . . cleared ILS 22 left
20,21 ,15,08 APPR - Avianca 052 heavy contact Kennedy tower . . .
21,21,15,23 TWR - Avianca 052 heavy Kennedy tower two two left you’re number three
following seven two seven traffic . . .
22) 21,19,58 TWR - Avianca 052 . . . cleared to land
23) 21,21,59 CAM2 - Slightly below glide slope
24) 21,22,44 CAM2 - Below glide slope
25) 21,22,52 CAM2 - Glide slope
26) 21,22,57 CAM2 - This is the wind shear
27) 21,23,08 CAM3 - Glide slope
28) 21,23,08 GPWS - Whoop whoop pull up
29) 21,23,09 CAM2 - Sink rate
30) 21,23,10 CAM2 - Five hundred feet
31) 21,23,11 GPWS - Whoop whoop pull up (repeated 3 times)
32) 21,23,13 CAM1 - Lights
34) 21,23,20 CAM1 - Where is the runway
36) 21,23,23., CAM1 - The runway where is it
37) 21,23,25., GPWS - Glide slope (repeated 2 times)
38) 21,23,27 CAM2 - I don’t see it I don’t see it
39) 21,23,28 CAM1 - Give me the landing gear up . . ,
40) 21,23,29 GPWS - Glide slope (repeated 2 times)
41) 21,23,33 CAM1 - Request another traffic pattern
42) 21,23,34 RD02 - Executing a missed approach . . .
(Continued on next page)

1
Time (H,M,S) Selected Diaglogue
43) 21,23,37 CAM3 - Smooth with the nose . . .

44) 21,23,39 TWR - Avianca 052 heavy Roger climb and maintain two thousand turn
left heading one eight zero
45) 21,23,43 CAM1 - We don’t have fue -
46) 21,24,06 CAM1 - Tell them we are in emergency
47) 21,24,08 RD02 - That’s right to one eight zero on the heading and we’ll try
once again we’re running out of fuel
48) 21,24,15 TWR - Okay
49) 21,24,15 Note - Avianca 052’s engines began flaming out from fuel
starvation less than 9 minutes after this point.
50) 21,24,17 CAM1 - What did he say
51) 21,24,22 CAM1 - Advise him we are emergency
52) 21,24,26 CAM1 - Did you tell him
53) 21,24,28 CAM2 - Yes sir I already advised him
54) 21,24,39 TWR - Avianca 052 heavy contact approach on . . .
55) 21,24,55 RD02 - Approach Avianca 025 heavy we just missed a missed
approach and we’re maintaining two thousand . . .
56) 21,25,03 APPR - Avianca 052 heavy. . . Climb and maintain three thousand
57) 21,25,08 CAM1 - Advise him we don’t have fuel
58) 21,25,10 RD02 - . . . Maintain three thousand and we’re running out of fuel sir
59) 21,25,12 APPR - Okay fly heading zero eight zero
60) 21,25,15 RD02 - Flying heading zero eight zero climb to three thousand
61) 21,25,28 CAM1 - Did you already advise that we don’t have fuel
62) 21,25,29 CAM2 - Yes sir I already advise him . . .
63) 21,25,29 CAM1 -OKAY
64) 21,26,35 APPR - And Avianca 052 heavy I’m gonna bring you about
fifteen miles north east and then turn you
back onto the approach is that fine with you and your fuel
65) 21,26,43 RD02 - I guess so thank you very much
66) 21,26,46 CAM1 - What did he say
67) 21,26,47 CAM2 - He said that 15 miles in order to get back to the localizer
68) 21,29,11 RD02 - Can you give us a final now Avianca 052 heavy
89) 21,29,20 APPR - Avianca 052 affirmative sir turn left heading . . .
70) 21,30,32 APPR - Avianca 052 climb and maintain three thousand
71) 21,30,36 RD02 - Negative sir we just running out of fuel we okay three thousand now okay
72) 21,30,44 APPR - Okay turn left heading three one zero sir
73) 21,32,39 CAM3 - Flame out flame out on engine number four
74) 21,32,43 CAM3 - Flame out engine number three essential on number two
75) 21,32,49 CAM1 - Show me the runway
76) 21,32,49 RD02 - Avianca 052 we just lost two engines and we need priority please
77) 21,32,54 APPR - Avianca 052 turn left heading two five zero . . .
78) 21,33,04 APPR - Avianca 052 heavy you’re one five miles from outer marker
maintain two thousand until established on the localizer cleared for ILS two two left
79) 21,33,12 RDO - Roger Avianca
80) 21,33,24 - End of flight 052 CVR and tower communications *
k I
airport?" The first officer responded at 2046:24, "it was Boston but we
can't do it now we, we, don't, we run out of fuel now."
A handoff controller, who was assisting the radar controller at the

NY ARTCC, and who was monitoring these radio transmissions, initiated a call
on the land-line at 2046:24 to the New York Terminal Radar Approach Control
(NY TRACON). At 2046:27, the handoff controller advised the NY TRACON
controller, "Avianca zero five two just coming on CAMRN can only do 5 more
minutes in the hold think you'll be able to take him or I'll set him up for
his alternate." The NY TRACON controller responded, "what's his speed now?"
The handoff controller replied, "ah, I'm not too sure to be quite honest with
you, holding speed." At 2046:38, the NY TRACON controller said, "slow him
to one eight zero knots and I'll take him he's radar three southwest of
CAMRN." The handoff controller replied, "one eighty on the speed, radar
contact and I'll put him on a forty [040 degree] heading." The New York
TRACON controller responded, "that's good." This coordination between the NY
ARTCC handoff controller and the NY TRACON controller terminated at 2046:44.
The NY ARTCC handoff controller later stated that he did not hear a
portion of the 2046:24 transmission from AVA052 and therefore did not pass
the information to NY TRACON that the flight crewmember had stated that
AVA052 could no longer reach its alternate airport.
After being advised by the handoff controller that the NY TRACON

would be able to accept AVA052, at 2046:47 the NY ARTCC radar controller
relayed, "Avianca zero five two heavy cleared to the Kennedy Airport via
heading zero four zero maintain one one thousand speed one eight zero."
After the first officer acknowledged the clearance, AVA052 was instructed to
contact the NY TRACON. Recorded air traffic control radar data indicates
that AVA052 departed the holding pattern at CAMRN intersection at 2047:OO.
At 2047:21, the first officer contacted the NY TRACON feeder

controller, " . ..we have ATIS information YANKEE with you one one thousand."
At 2047:27, the feeder controller replied, "Avianca zero five two heavy New
York approach thank you reduce speed to one eight zero if you're not already
doing it you can expect an ILS two two left altimeter two niner six niner
proceed direct Deer Park."
AVA052 was then provided with routine radar service, including

descents to lower altitudes and heading changes, to place it in sequence with
other airplanes that were en route to IFR approaches at JFK. At 2054:40,
the feeder controller cleared AVA052 to, " . ..turn right right turn heading
two two zero I'm going to have to spin you sir."5
At 2056:16, the feeder controller advised, "Avianca zero five two

I have a windshear for you ah at fifteen ah increase of ten knots at fifteen
hundred feet and then an increase of ten knots at five hundred feet reported
by seven twenty seven." At 2056:25, the first officer acknowledged receipt
of the windshear advisory.
’ “Spin you” i s a n o n s t a n d a r d t e r m t h a t r e f e r s t o m a k i n g a 360’ t u r n .

7
At 2102:39, AVA052 was instructed to contact the NY TRACON final

controller. The first officer acknowledged the new frequency, "one one
eight point four so long" and at 2103:07 contacted the NY TRACON final
controller, reporting level at 5,000 feet. During the next 7 minutes, AVA052
received routine radar service, including several heading changes, and
further descent clearances to 3,000 feet and finally to 2,000 feet.
At 2103:46, the flightcrew began to discuss the procedure for

go-around, with 1,000 pounds or less of fuel in any tank. At 2103:56, the
second officer stated, in Spanish, "then the go-around procedure is stating
that the power be applied slowly and to avoid rapid accelerations and to have
a minimum of nose up attitude."
At 2108:34, AVA052 was instructed to descend to 3,000 feet. The

first officer acknowledged and at 2108:51 AVA052 descended out of 5,000 feet
for 3,000 feet.
The following intracockpit conversations in Spanish (recorded on

the CVR) commenced at 2109:21: The first officer stated, "they accommodate
us ahead of an--." At 2109:27, the captain said, "what," and the first
officer stated, "they accommodate us." At 2109:29, the second officer said,
"they already know that we are in bad condition." At 2109:30, the captain
said, "no they are descending us." At 2109:35, the first officer said,
"one thousand feet." The captain said, "ah yes." At 2109:38, the second
officer said, "they are giving us priority."
At 2111:07, the final controller stated, "...you are one five

miles from the outer marker maintain two thousand until established on the
localizer cleared ILS two two left." Figure 2 depicts the ILS runway 22L
approach chart.
At 2111:16 (CVR), the captain said, "select the ILS on my side."

The first officer responded, "the ILS is number one - one hundred ten point
nine is set." At 2111:32 (CVR), the captain said, "give me flaps fourteen."
At 2111:33 (CVR), the first officer said, "we are thirteen miles from the
outer marker." At 2111:55, AVA052 was instructed to maintain an indicated
airspeed "... of one six zero if practical." At 2112:05 (CVR), the captain
If II
called for . ..flaps twenty five." The first officer responded, "flaps
twenty five." At 2115:08, the NY TRACON controller instructed, "Avianca
zero five two heavy contact Kennedy tower one one niner point one good day."
The first officer acknowledged the instructions.
8
JEPPESEN
NEW YORK, NY
AT15 Arrival (Ml 117.7 (SW) 115.4 KENNEDY INTL
MWYQI( *ppd (RI 127.4 I L S R w y 22L
KEMDV lower 119.1 lot 110.9 IIWY
- a. - -
croud 121.9 6Ap 1. E/w 13’,
?!
aa0
11\544’
(\Ul’
.
ROSL Y
282.2 lS.3
2000
na na
1 OERS ROSl Y
Dll.?lIbwI~s
ussso
- Amoatt: Climb to 500’ than clinv bing LEFT turn to 3000’ outbound vi
JFK VOR R- 190 to CHANT INT/D 19.0 and hold.
STRAIWdIN LANDING RW 221 CIRCLE~T
__-. I - .- I‘ lot ICI out)
Figure 2.--Jeppesen Approach Plate of ILS to runway 22 left at JFK.

9
At 2115:19, the first officer contacted JFK Tower, stating that

AVA052 was "... established two two left." At 2115:23,6 the tower controller
responded that AVA052 was number three to land following a Boeing 727 that
was on a g-mile final.
At 2116:19 (CVR), the captain asked, "can I lower the landing gear
yet?" The first officer responded, "no I think it is too early now."
At 2117:17, JFK tower controller inquired, "Avianca zero five two

what's your airspeed." The first officer responded, "Avianca zero five two
one four zero knots." At 2117:30, tower requested, "Avianca zero five two
can you increase airspeed one zero knots." At 2117:41, the first officer
responded, "okay one zero knots increasing." At 2117:55 (CVR), the captain
said, "tell me things louder because--I'm not--hearing it."
At 2118:ll (CVR), the first officer said, "we are three miles to
the outer marker now." At 2118:15, the captain said, "resetting the ILS."
At 2118:17, the first officer said, "here it is already intercepted." At
2118:32, the first officer said, "glideslope alive."
At 2119:09 (CVR), the captain said, "lower the gear." The first
officer responded, "gear down." At 2119:21 (CVR), the captain said, "give me
forty." The first officer responded, "forty." At 2119:30 (CVR), the captain
said, "mode selector approach landing checklist." The second officer
responded at 2119:32, "landing check." At 2119:58, JFK tower called,
"Avianca zero five two two two left wind one nine zero at two zero cleared to
land." At 2120:10, JFK tower requested, "Avianca zero five two say
airspeed." The first officer responded, "zero five two is ah one four five
knots."
At 2120:17 (CVR), the captain said, "give me fifty," and at

2120:21, he said, "are we cleared to land no?" The first officer responded
at 2120:23, "yes sir we are cleared to land." At 2120:28 (CVR), the first
officer said, "localizer to the left slightly below glideslope." At 2120:33
(CVR), the second officer said, "stand by flaps fifty landing checklist
complete." At 2120:39, the captain said, "flaps fifty now." At 2020:41, the
second officer said, "fifty green light final set." At 2120:48 (CVR), the
first officer said, "below glideslope."
At 2121:07, JFK tower requested, "Avianca zero five two heavy can
you increase your airspeed one zero knots at all." The first officer
responded, "yes we're doing it."
6 In some cases, the times recovered from the CVR tape and annotated on
the CVR transcript differ by 1 or more seconds from the times annotated on
the ATC transcript. The reason for this difference involves the manner in
which t h e F A A r e c o r d s the times from the ATC tape versus the manner of
recording the times from the CVR tape. F o r t h e s a k e o f c o n s i s t e n c y , where
the times differ, the times transcribed on the CVR transcript are used in
this report instead of the ATC times.
II n
10
At 2121:41 (CVR), the captain said, "localizer glideslope one

thousand feet stand by for lights." At 2121:59 (CVR), the first officer
said, "slightly below glideslope." At 2122:05, AVA052 was about 3.2 miles
from the approach end of runway 22L. At 2122:07 (CVR), the first officer
said, "one thousand feet above field."
At 2122:57 (CVR), the first officer said, "this is the windshear."

At 2123:08 (CVR), the second officer said, "glideslope." At 2123:08, the
first officer said, "glideslope;" at 2123:09, "sink rate; and at 2123:10,
"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).7
Between 2123:25 and 2123:29, there were four "glideslope" deviation alerts
from the GPWS. At 2123:23 (CVR), the captain asked "the runway where is it?"
At this time, AVA052 was 1.3 miles from the approach end of runway 22 left at
an altitude of 200 feet. At 2123:27 (CVR), the first officer said, “I don't
see it I don't see it." At 2123:28 (CVR), the captain said, "give me the
landing gear up landing gear up." Figure 3 depicts the profile view of
AVA052's ILS approach path and go-around.
At 2123:34, the first officer radioed, "executing a missed

approach Avianca zero five two heavy." The JFK tower controller responded,
"Avianca zero five two heavy roger ah climb and maintain two thousand turn
left heading one eight zero." The first officer replied, "climb and
maintain one ah two thousand one eight zero on the heading.
At 2123:54 (CVR), the captain said, "flaps twenty five." The

second officer said, "two thousand feet." The second officer responded at
2123:56, "flaps twenty five." At 2124:00 (CVR), the captain said, “I don't
know what happened with the runway I didn't see it." Also at 2124:00, the
second officer said, “‘I didn't see it," and the first officer said, “I
didn't see it."
At 2124:04, JFK tower controller stated, "Avianca zero five two

you're making the left turn correct sir." At 2124:06 (CVR), the captain
said, "tell them we are in emergency." The second officer said, (CVR), "two
thousand feet." At 2124:08, the first officer replied to JFK tower, "that's
right to one eight zero on the heading and ah we'll try once again we're
running out of fuel." At 2124:15, JFK tower stated, "okay." At 2124:22
(CVR), the captain said, "advise him we are emergency." At 2124:26, the
captain said, "did you tell him." The first officer replied, 'yes sir, I
already advised him."
7 T h e GPUS i s a c t i v a t e d b e t u e e n 5 0 a n d 2 , 4 5 0 f e e t a g l r a d i o a t t i t u d e ,
a n d w i 11 g i v e a d v a n c e w a r n i n g a l e r t s t o t h e f L i g h t c r e w u h e n o n e o r m o r e o f
its five thresholds is exceeded: Mode 1 - Excessive descent rate, Mode
2-excessive t e r r a i n closure rate, Mode 3 - Altitude loss after takeoff or
go-around, Mode 4 - Unsafe terrain clearance while not in the landing
c o n f i g u r a t i o n , a n d M o d e 5 - Below g l i d e s l o p e d e v i a t i o n a l e r t s .
n’as owsl CvREvNll CvREvsnl
22)2l,l@,S&TWFt -AMmcs052...CkrndtoM 37) 2123.25.ww6 --~~-2~~)
23)2101,5%cAM2 -sllglmybdowgl~~ 35) 21$?3n.,cAM2 -Idcul’tsealtIdarftswlt
24)21?2#U.,cAM2 -wowgklaabps 39) 2133~.,cAMl -Ghn,memslmdnggenrup...
26)21#22#52.,cAM2 -Qlldeabps 40) 2123.29..ww6 -Qlkbnlope(rspe4eU2Umem)
26)21,22,57..CAM2 -TMsbUmWndshmr 41) 21S?3#3333.,cAMl -ReqwatlulolhariIdfk~
27)2l~owAM3 -auckabPs 42) 21,23,34.,RDO2 -6xsadngambssdspproachAvfsncs052hesvy
~)2123*OB.,GPW8 - whoop whoop plll up 43) 21.23~7.SAM3 -6moolhwlththanosaamoothmthamae...
20) 2133,0@..cAM2 - 6hk mm 44) 21,23,39.,TwR -AvisncslJ62henvy~climbandmMtain
30) 21,23,lO.,cAM2 - Phfe hmuledfwt ~thowandtumbftheasMngoneeiigMzsm
31)212323,11..(3pws -whoopwhoopFd’@(~311mes) 45) 2123,u..cAM2 -WOdOfl~hOW3fU9-
32) 21,~13..w1 - Ugms 49) 21,24,oB.,cAMl -Tellthsrnm,sreinsmqmcy
33) 21.23.14.,GPw6 - whoop whoop P’AI up (repaaad 4 lfmea) 47) 21,24,08.,RDO2 -marstightt0~sight20f0~tihdingand
wMllryorceqdnwahnmirgwtoffud
34)21S3,2o.,cAMl -~mbtlmr’n’way
2400.0 33 21 l23*.,2.,GPWS - whoop whoop pull up (rapead 3 tlme3)
38)2lCz3,23.,cAMl -msN’lway~nirit
49) 21,24,15.,lWR -0W
Upper Limit
Limit
0 = Radar Return
•k = Event Location
Note: Limits correspond to full

deflection of glideslope needle
3.00 3.50 4.00 6.00 7.00
Distance - Nautical Miles

Marker
Figure 3. --AVA052 ILS approach--profile view.

12
At 2124:32, JFK tower instructed, "Avianca zero five two heavy

continue the left turn heading one five zero maintain two thousand." The
first officer responded, "one five zero maintaining two thousand Avianca
zero five two heavy." At 2124:31 (CVR), the captain said, "flaps four--
fifteen." At 2124:39, JFK tower radioed, "Avianca zero five two heavy
contact approach on one one eight point four."
At 2124:55 (CVR), the captain said, "flaps fifteen." Then, also at

2124:55, the first officer made the radio call, "approach Avianca zero five
ah two heavy we just missed a missed approach and ah we're maintaining two
thousand and five on the...." At 2124:58 (CVR), the flight engineer replied
to the captain, "flaps fourteen." At 2125:07, the NY TRACON controller
replied to the radio call, "Avianca zero five two heavy New York good evening
climb and maintain three thousand."
At 2125:08 (CVR), the captain said, "advise him we don't have

fuel." At 2125:10, the first officer made the radio call, "Climb and
maintain three thousand and ah we're running out of fuel sir." At 2125:28
(CVR), the captain said, "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 2126:27, the NY TRACON final controller instructed, "Avianca

zero five two heavy turn left heading zero seven zero." The flightcrew
responded, "heading zero seven zero Avianca zero five two heavy." At
2126:35, the NY TRACON final controller stated, "and Avianca zero five two
heavy ah I'm going to bring you about fifteen miles northeast and then turn
you back on 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 a final
now...?" The NY TRACON final controller responded, "...affirmative sir turn
left heading zero four zero." At 2130:32, the final controller stated,
"Avianca fifty two climb and maintain three thousand." At 2130:36, 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."
At 2130:55 (CVR), the captain said, "set flaps fourteen." The

first officer responded, "fourteen degrees." At 2130:55, the controller
stated, "and Avianca fifty two fly a heading of three six zero please." At
2130:56 (CVR), the first officer replied to the captain, "fourteen degrees."
The captain said, "tell me heading what." At 2130:58, the first officer
responded to the controller, "okay we'll maintain three six zero now." At
2130:59 (CVR), the second officer stated, 'three six zero now."
At 2131:01, the NY TRACON controller stated, "okay and 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."
13
At 2131:22 (CVR), the captain asked, "three sixty no?" The first
officer replied, "three sixty." At 2131:26 (CVR), the captain said, "flaps
fourteen." At 2132:07, the flight was instructed to turn left to a heading
of 3300.
At 2132:14 (CVR), the first officer said, "three three zero the
heading." At 2132:39 (CVR), the second officer said, "flame out flame out on
engine number four." At 2132:42 (CVR), the captain said, "flame out on it."
The second officer then said, "flame out on engine number three essential on
number two or number one." At 2132:49 (CVR), the captain said, "show me the
runway."
At 2132:49 the first officer radioed, "...we just ah lost two

engines and ah we need priority please." The final controller then
instructed AVA052 to turn to a heading of two five zero degrees, advised the
flight that it was fifteen miles from the outer marker and cleared for the
ILS approach to runway 22 left. At 2132:57 (CVR), the first officer said,
"two five zero."
At 2133:04 (CVR), the captain stated, "select the ILS let's see."
At 2133:15 (CVR) the captain stated "that no--that," and at 2133:22 he
asked, "did you select the ILS?"
At 2133:07, the final controller informed the flight, "...you're

one five miles from outer marker maintain two thousand until established on
the localizer cleared for ILS two two left."
At 2133:23 (CVR), the first officer replied, "it is ready on two.'I

This radio transmission was the last clearance acknowledged by AVA052.
At 2133:24, the CVR ended.
At 2134:00, the NY TRACON final 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 residential
home. There was no fire.
1.2 Injuries to Persons
Flight Cabin
Crew Crew Passenoers Infants Other Total
Fatal 3 5 64 1 73
Serious 0 72 8 8 81
Minor
None 0 A
0 ii A2 r 0 i
Total 3 6 138 11 0 158
14
Of the 158 persons aboard, 73 were fatally injured, including the 3

flight crewmembers and 5 of the 6 flight attendants; 81 persons were
seriously injured, including the surviving flight attendant and 8 infants;
and 4 persons received minor injuries.
There were 149 passengers aboard the flight, consisting of the

following: 61 adult males and 61 adult females, whose ages ranged from
19 years to 77 years. There were 16 children, 8 males and 8 females, whose
ages ranged from 3 years to 15 years. There were 11 infants, 8 males and 3
females, whose ages ranged from 4 months to 27 months.
An airplane Seating Diagram, showing the placement of occupants

(flightcrew, attendants and passengers) and extent of injury of each person
(minor, serious or fatal) is provided as figure 4.
1.3 Damage to Airplane
The Boeing 707-321B was destroyed upon impact. The airplane was
valued by the airline at approximately $5 million.
1.4 Other Damage
Several trees were sheared off just prior to and at the time that
the airplane impacted with the ground. The starboard side of the forward
fuselage fractured the wooden deck of a residence. Property damage is
estimated at approximately $250,000.
1.5 Personnel Information
Although the captain had flown previously on international flights

with either the copilot or the flight engineer, the accident flight was the
first time that all three flight crewmembers had flown together as a crew.
1.5.1 The Captain
The captain, born November 20, 1938, was a citizen of the Republic
of Colombia. His date of employment with Avianca Airlines was May 17, 1962.
He possessed a U.S. Airline Transport Pilot Certificate. The most

recent date of issuance and rating information for the certificate was
November 26, 1976, for a multiengine land, center-line thrust, Boeing 727
(B-727). The captain also possessed a Colombian Air Transport Pilot Rating,
issued December 4, 1969, with the privileges and limitations of copilot
B-727, B-720, and B-707, and pilot HS-748, B-727, and B-707. He was issued a
Colombian class I medical license on December 21, 1989, with no limitations.
The captain's initial transition training in the B-707 for the

pilot-in-command position was completed satisfactorily in June 1987. The
training included eight simulator training periods totaling 21 hours, a
3-hour check in the simulator and a l-hour check flight in the airplane with
a Colombian civil flight inspector.
a
15
L-l Main
Boarding - - R-l Forward
Galley Door
Door
Lounge
First Class
-II
Coach -
L-2 R-2
Type III Type III
Overwing Overwing
Exit I I Exit
L-3 R-3
Because not all seats were assigned,

and some passengers moved to
different seats after boarding, precise
seating arrangements in relation to
injuries could not be determined.
L-4 Aft R-4 Aft

Entry - B - Galley
Door Door
\ NOTE: Diagran I is not to scale
Figure 4. --AVA052 cabin seating diagram.

16
The captain completed recurrent ground and simulator training in

the B-707 in August 1988. His most recent recurrent training in the B-707
was completed on June 11 and 12, 1989. His record of training reflected that
he demonstrated satisfactory performance in various maneuvers and procedures
including "Normal Flight Director ILS and Land," "Wind Shear During
Approach," and "GPWS Training Procedures." The blocks on his record of
training for "Coupled ILS" and "Raw Data ILS" were blank. The captain's
record of recurrent training did not indicate whether he had flown instrument
approaches into JFK in a flight simulator.
The captain's initial line check into JFK was completed in

September 1987. His most recent line check into JFK was completed in
September 1989. Items checked as having been satisfactorily demonstrated
during his most recent line check included the following:
Item 4 Flight plan analysis, understanding of fuel

required, fuel planning - destination and alternate,
weather reports - destination and alternate;
Item 6 Compliance with FAA regulations;
Item 13 Use of radio facilities;
Item 16 Communication, techniques, and terminology in

Spanish and English;
Item 18 Descent procedures, top of descent speeds,

altitudes, coordination with air traffic control,
and approach techniques;
Item 19 Deviation to alternates, minimums considering the

meteorological conditions and the fuel conditions,
and use of navigational charts;
Item 20 Approaches [the ILS block on the line check form

was checked];
Item 24 Judgement.
In the space on the form for the recording of observations, the

inspector pilot wrote, "good work."
From January 1989, to and including the date of the accident

flight, the captain made 14 flights to JFK from Colombia in Boeing 707
airplanes.
As of January 25, 1990, the captain had accrued a total flight

time of 16,787 hours, 1,534 of which were in the B-707. His total night
flying experience was 2,435 hours, 478 of which were in the B-707.
17
The instrument time that the captain and the other cockpit
crewmembers individually accrued is not known. The airline did not record
individual pilot instrument time.
The captain's total flight time in B-707 airplanes during November

and December 1989, and January 1990, were 37:58 (hours:minutes), 26:40, and
41:54, respectively. The captain did not accrue any flight time during the
24 hours prior to departure from Bogota on the accident flight.
After the captain completed B-707 upgrade training, he did not fly
other aircraft for Avianca, in accordance with the airline's policy and
procedures.
The captain was also a pilot in the Colombian Air Force Reserve and
a member of the Colombian Air Line Pilots Association. He had no record of
previous accidents.
1.5.2 The First Officer
The first officer/copilot was born January 2, 1962. He was a

citizen of the Republic of Colombia. Employed by Avianca Airlines on
October 1, 1986, he possessed a U.S. FAA commercial pilot's license, with a
latest date of issuance of April 7, 1983. He possessed FAA license ratings
of "airplane, single and multiengine land, and instrument, airplane." The
first officer also possessed a Colombian commercial pilot's license, issued
originally in August 1983, with the privileges and limitations of single
engine land up to 5,670 kilograms (12,500 pounds), and copilot: B-727 and
B-707. He was issued an FAA first class medical certificate on January 25,
1989, with no limitations.
During October 1989, the first officer transitioned from the B-727
to the B-707. The transition period included 14 hours of simulated flight
and 135 hours of ground instruction. The airline states that, in accordance
with the requirements of the Colombian Civil Aviation Administration
(Departamento Administrativo de Aeronautical Civil - DAAC), the first officer
flew 30 hours as an observer in the jump seat of the B-707.
The first officer's initial line check in a B-707 was on a flight

from Bogota to JFK in December 1989, the month prior to the accident.
Instructors' comments in the first officer's training records indicated
normal progression and performance. After the first officer completed B-707
transition training, he did not fly other aircraft for Avianca Airlines.
From January 1989 until the accident flight on January 25, 1990,
the first officer made the following B-727 and B-707 flights from Colombia to
New York:
Boeing 727: January 18, March 17, April 27, May 5, June
3, and 17, and July 4 and 14, 1989
Boeing 707: December 8, 18, and 25, 1989, and January 5

and 25, 1990
18
The first officer's total flight time was 1,837 hours. He flew 64
flight hours as copilot in the B-707. His total night flying time was
408 hours, 13 of which were in the B-707.
The first officer's flight times in the B-707 during November and
December 1989, and January 1990 were 00:50 (hours:minutes), 35:26, and
28:26, respectively. The first officer flew 06:55 during the 72-hour period
prior to the accident.
1.5.3 The Flight Engineer
The fllight engineer (second officer), born January 9, 1945, was a

citizen of the Republic of Colombia. He was employed by Avianca Airlines on
May 9, 1966.
The flight engineer held a Colombian flight engineer's license,

issued July 27, 1973. His license privileges and limitations were for the
B-727, B-720, and B-707. He was issued a Colombian medical certificate,
dated February 6, 1989, with no limitations.
The flight engineer requalified in the B-707, coming from the

B-727, in October 1989. His requalification included 60 hours of ground
school, and 20 hours of simulator training given over a 5-day period. Upon
completion of training, he was given a E-hour check ride in a B-707
simulator. His training record indicates that he demonstrated satisfactory
knowledge of B-707 flight engineer responsibilities in: takeoff, climb,
cruise flight, descent, holding and landing.
His initial line check in the B-707, after requalification, was in

October 1989, on an out-and-return flight between Bogota and Medellin. The
check flight engineer's comments included: "fuel computations satisfactory."
After the flight engineer completed B-707 requalification training, he did
not perform as a flight engineer on any other aircraft for Avianca Airlines.
From January 1989, up to the accident flight, he performed as the

flight engineer on the following B-727 and B-707 flights between Colombia
and New York:
Boeing 727: May 1, and June 19, 1989
Boeing 707: November 9, and December 21 and 28, 1989, and

January 22 and 25, 1990.
The flight engineer's total flight time was 10,134 hours, of which
3,077 hours were in the B-707. His total night flying experience was
2,986 hours, of which 1,062 hours were in the B-707.
The flight engineer's flight time in the B-707 during November and
December 1989, and January 1990 were 62:04 (hours:minutes), 52:48, and 48:40,
respectively. He flew 11:37 during the 72 hour period prior to the accident.
He had not flown during the 24 hour period prior to AVA052's departure from
Bogota.
19
1.5.4 Cabin Crew
There were six cabin crewmembers. Five sustained fatal injuries in

the impact. The lead cabin crewmember, seated in the forwardmost portion of
the cabin, survived.
Training records for the cabin crewmembers were requested from the
airline but were not received by the Safety Board.
1.5.5 The Flight Dispatcher
Although AVA052 was not issued a dispatch release for the leg of
the flight from Medellin to New York, the airline had a flight dispatcher on
duty at its facility at Jose Maria Cordova Airport, near Medellin.
The flight dispatcher, born December 30, 1953, was a citizen of the
Republic of Colombia. On duty at the time AVA052 departed Medellin, he
recorded a runway departure time of 1508 for the flight. The dispatcher's
duty period ended at 2030.
The flight dispatcher possessed a Colombian aircraft dispatcher's

license, with a latest date of issuance of September 27, 1979. His
dispatcher's license was listed for B-707, B-720, B-727, and B-747
airplanes.
His initial dispatch training was completed in November 1977. The

training consisted of 110 hours of instruction, given over a 22-day period.
The flight dispatcher had received recurrent and familiarization training
during May 1982 and May 1985.
Regarding the interpretation of meteorological and navigational

information, the dispatcher's training records showed no instruction. The
spaces on the training forms that contained the words "meteorology" and
"navigation" were not filled out.
1.5.6 Air Traffic Controllers
U.S. air traffic controllers were involved in handling AVA052 from

the time that the flight entered into U.S. controlled airspace via the Miami
ARTCC. The flight traversed the airspace of the following air traffic
control facilities while en route to JFK: Miami ARTCC, Jacksonville ARTCC,
Washington ARTCC, New York ARTCC, NY TRACON, and JFK tower.
The backgrounds of controllers involved in more critical portions

of the flight are as follows. The New York ARTCC R67 (radar) controller,
age 24, was a full performance level air traffic control specialist. He was
employed by the FAA on April 9, 1985. He graduated from the ATC School at
the FAA Academy in April 1986, and was facility rated in Area E on July 26,
1989. He was medically certified to perform the duties of air traffic
control with no waivers or limitations. He was not a pilot, and he had no
previous experience as a military air traffic controller.
20
The New York ARTCC H67 (handoff) controller, age 30, was a full
performance level air traffic control specialist. He was employed by the FAA
on April 30, 1982. He graduated from the ATC School at the FAA Academy in
July 1982, and was facility rated in Area E on January 22, 1986. He was
medically certified to perform the duties of air traffic control with no
waivers or limitations. He was not a pilot, and he had no previous
experience as a military air traffic controller.
The New York TRACON CAMRN/LENDY controller, age 33, was a full
performance level ATC specialist. He was employed by the FAA on April 5,
1982, and was facility rated in the Kennedy area on June 11, 1986. He was
medically certified to perform the duties of air traffic control with no
waivers or limitations. He was not a pilot. He had 8 years experience as a
military air traffic controller and had 2 years experience as an air traffic
controller while employed by a private corporation.
The New York TRACON Final Vector controller, age 33, was a full
performance level ATC specialist. He was employed by the FAA on October 17,
1982. He graduated from the ATC School at the FAA Academy and was assigned
to the Philadelphia tower for approximately 4 months before his assignment to
the New York TRACON. He was facility rated in the Kennedy area on October 5,
1984. He was medically certified to perform the duties of air traffic
control with no waivers or limitations. Although not required for medical
certification, he wore glasses to correct distant vision, and he was wearing
his glasses while working the Final Vector position at the time of the
accident. In addition to being certified in the Kennedy area, he also
performed the duties of Traffic Management Coordinator. He was not a pilot,
and he had no previous experience as a military air traffic controller.
The New York TRACON, Kennedy Sector, Area Supervisor, age 37, was a
full performance level controller and area supervisor. He was employed by
the FAA on January 21, 1982. He was first assigned to the Newark sector as
an air traffic control specialist and then as a Plans and Procedures
Specialist for the Newark sector. In 1987, he was promoted to area
supervisor, and in 1989, he was assigned to the Kennedy sector.
The Area Supervisor had been on duty from 0700 until 2045. He was
not on duty at the time of the accident. Prior to being off duty, he
assigned an air traffic controller from the Kennedy sector to perform the
duties of controller-in-charge.
He was medically certified to perform air traffic control duties,

with no waivers or limitations. He was a private pilot. He had no previous
experience as a military air traffic controller.
The JFK tower local controller, age 32, was a full performance
level air traffic control specialist. He was employed by the FAA on July 11,
1982. He was facility rated on February 4, 1986. He was medically certified
to perform air traffic control duties and was required to wear glasses to
correct for distant vision while performing controller duties. He was
wearing his glasses while he was working the local control position. He was
21
not a pilot, and he had 3 l/2 years experience as a military air traffic
controller.
1.6 Airplane Information
1.6.1 General
The Boeing 707 (B-707) type airplane first entered cotmnercial

service in September 1958. Currently, about 157 B-707s are registered
outside the United States, flown by 61 operators. The B-707 is a
transport-category airplane, certificated under Federal Aviation
Regulations.
The accident airplane, with Colombian registration HK 2016, was a

Boeing 707 series 321B. The 300 series was designed to serve on very long
route segments of up to 6,000 miles, at cruising speeds of up to 0.90 Mach,
and at cruising altitudes up to 42,000 feet msl.
HK 2016 was manufactured in June 1967. Avianca Airlines purchased

the airplane from Pan American World Airways Inc., in February 1977. At the
time of the accident, HK 2016 had accrued a total of 61,764 airframe flight
hours.
A review of the maintenance records for HK2016 revealed that the

airplane had been inspected and maintained in accordance with Avianca's
maintenance program that had been approved by the Colombian DAAC. The review
showed that all required items had been accomplished within the times
specified.
A review of maintenance discrepancies logs for the 3 months before

the accident revealed six open items, none of which could be considered
related to fuel leaks or similar problems. All other items had been cleared
by corrective actions. The last calibration of the fuel indicating system
was in June 1989 during the last C-check. The records review indicated
several recurring problems with the autopilot, primarily the ability of the
autopilot to hold altitude. The records indicated that corrective actions
had been taken for these writeups. There had been two previous writeups on
the flight data recorder for failure in the test mode. The corrective action
stated that the foil had been inspected and found to be "OK."
Avianca Airlines had retrofitted each of its four Boeing 707-321B

airplanes with a Tracer/Shannon Engine Quiet Modification, pursuant to a
supplemental type certificate. All four Pratt & Whitney JT3D-3B engines on
each of the four airplanes had received the modification, also known as a
"hush kit." With the modification installed, the noise level produced by the
Boeing 707-321B was in compliance with Stage 2 requirements, in accordance
with 14 CFR Part 36, appendix C.
The supplemental We certificate for the engine quiet

modification required that a supplement be issued to the FAA-approved B-707
airplane flight manual (AFM). A copy of the supplement was carried aboard
AVA052. It stated, in part, on page 2, dated February 22, 1985:
22
The following performance decrements shall be applied to the

takeoff performance-limited weights determined from the basic AFM:
0 Takeoff field length - subtract 1,200 lbs.
0 Takeoff climb (including obstacle

clearance) subtract 2,800 lbs.
On page 3 of the supplement, with an entry date of December 9,

1986, it notes:
For normal operation, landing must be accomplished at Flaps

25... Use of Flaps 40 or 50 is prohibited except as provided
in the Emergency Operating Procedures section of this Airplane
Flight Manual Supplement.
and
Use of auto-pilot and/or auto-throttle (if installed) is not

permitted for Flaps 25 final approach and landing from a
minimum of 500 feet above the destination airport.
Avianca Airlines' personnel stated that, as a result of the engine

quiet modification, a fuel overburn of 5 percent was factored into the
airplane's performance calculations. An additional 5 percent overburn was
factored in for consideration of the airplane's degraded performance because
of aging.
1.6.2 Flight.Plan and Performance Information
The flight plan for the AVA052 route segment from Medellin to JFK
was computer generated by the Society International Telecommunications
Association (SITA) headquarters in Paris. SITA forwarded the flight plan to
the Avianca dispatcher at 0647, January 25, via teleprinter.
The flight plan was based upon a combination of airplane

performance data supplied by the airline and upper level forecast weather
conditions that existed at the time of the flight plan request.
The flight plan recovered from the airplane contained the planned
routing and fuel required for the flight. It was based upon an airplane zero
fuel weight of 182,000 pounds. The weight at the beginning of the takeoff
roll and the landing weight were entered as 254,430 and 198,910 pounds,
respectively. The flight plan called for AVA052 to depart Medellin via the
Alexandria One standard instrument departure (SID) to TENDON. The great
circle distance from Medellin to JFK was shown as 2,067 nautical miles (nm)
with an air distance of 2,069 nm.
23
The flight plan indicated that the alternate airport was Boston
Logan Airport (BOS), and that BOS was 183 nm from JFK. It showed that the
estimated en route altitude to BOS would be FL230, if diversion to the
alternate were necessary, and that a wind correction of plus 65 knots had
been factored into the fuel required to fly from JFK to BOS.
The flight plan listed the following information regarding the

amount of fuel required for the flight correlated with flight time:
Fuel (lbs.) Time
Destination: JFK 55,520 4 hours 40 minutes

Reserve 4,510 28 "
Alternate 7,600 30 "
Hold 4;800 30 ”
Total Required 72,430 6 hours 08 minutes
Taxi 1,500
Total blocks 79,930
The Avianca Airlines dispatcher at Medellin prepared the Fuel

Loading Instructions form for the flight using computations based on the fuel
requirements of the flight plan. The original form was given to the flight
engineer of AVA052. Copies of the form were forwarded to the airline
maintenance personnel responsible for assisting in the refueling operation,
as well as the fueling contract facility.
Based upon a fuel density of 6.7 pounds per gallon, the dispatcher
ordered a total block fuel load of 78,000 pounds, with the fuel distributed
symmetrically into main tanks Nos. 1 and 4, and 2 and 3, respectively. The
fuel loading instructions reflected that there was no usable fuel in the
center tank or the outboard auxiliary tanks. At Medellin, all fuel was
loaded into Nos. 1, 2, 3, and 4 main wing tanks. The fuel requested included
4,070 pounds of "extra/stored" fuel (78,000 minus 73,930 pounds). Avianca
personnel stated that the additional "top off" fuel was placed on board to
bring the airplane's takeoff weight up to the maximum allowable for
runway 18, the planned departure runway.
The Fuel Loading Instructions form indicated that it was necessary

to add 11,642 pounds of fuel in order to obtain the 78,000 pounds requested
by the dispatcher. The flight log for the airplane recovered from the
accident site contained an entry indicating that the flight from Bogota
landed at Medellin with 67,200 pounds of fuel remaining. It was not
stipulated whether this figure reflected touchdown or block-in fuel;
however, Avianca personnel stated that such an entry normally reflects the
pretaxi or block fuel. The two figures (fuel aboard and fuel added) yield a
total "blocks" fuel load of 78,842 pounds.
Airline personnel also stated that pursuant to standard operating

procedure, a drip stick, in addition to the fuel bay and cockpit fuel panel
gauges, was used to ensure that the requested fuel was properly loaded into
the airplane's fuel tanks.
1
24
The dispatcher's initial request for fuel was based upon the
flight departing Medellin from runway 18. He completed the Weight and
Balance and Load Summary form for the flight based upon the use of that
runway. However, because ambient conditions permitted, the captain and
dispatcher decided to use runway 36, which would allow a higher takeoff gross
weight. The captain subsequently requested that an additional 2,000 pounds
of fuel be taken aboard the airplane. Notations on the Weight and Balance
and Load Summary form noted that the gross weight of the airplane at takeoff
was corrected from 254,799 to 256,799 pounds at 28 percent mean aerodynamic
chord (MAC). The limitations' block on the form reflected a takeoff gross
weight of 254,800 pounds (for runway 18). The forward and aft center of
gravity limits were 16 and 35 percent of MAC, respectively.
A notation on the airplane's flight log found at the accident site

indicated that 80,000 pounds of fuel were on board the airplane at Medellin.
However, entered on page 1 of the flight plan, in the area below the total
planned fuel required for the flight, was the handwritten number "81,000."
Also found at the accident site was the Fuel and Gross Weight
Computations (FGC) form for the flight from Medellin to JFK. It is the
responsibility of the flight engineer to enter data on this form. The form
is used by the flight engineer to track and log the fuel on board an airplane
at various stages during a flight. Data, printed by hand on the form,
included the following: zero fuel weight - 178,300 lbs., block fuel-
80,500 lbs., and block gross weight - 258,800 lbs. Individual fuel quantity
gauge readings noted and recorded before AVA052's departure from Medellin
indicated that there was no usable fuel in the airplane's outboard reserve
tanks or in the center tank. The No. 1 and No. 4 fuel tank gauge readings
were noted as 15,800 pounds. The No. 2 and No. 3 fuel tank gauge readings
were noted as 25,000 and 25,400 pounds. The sum of these values is
82,000 pounds. This figure, "82.0," was entered in the block entitled "gauge
sum."
Airline personnel stated that the flight engineer would have made a
handwritten entry on the form, indicating a fuel total based on the cockpit
gauges, just prior to the airplane taking the runway for takeoff. The
airline used 1,500 pounds as taxi fuel at Medellin.
The Fuel and Gross Weight Computation form for AVA052 also
included notations for ,the total amount of fuel used and remaining at five
points along the route of flight. They were made at the top of the climb
(TOC), during cruise, and at the top of the descent (TOD). According to the
notations, the TOC to FL350 occurred at 1539 and required 31 minutes, burning
12,600 pounds of fuel, including fuel required for taxi at Medellin. Fuel
quantities were recorded at 1640, while the flight was in cruise at FL350.
At that point, 27,300 pounds of fuel had been used and 55,000 pounds
remained. Another TOC computation was recorded at 1739 at FL370. At that
point, fuel used was 40,300 pounds, with 41,200 pounds remaining. At 1839,
with the flight in cruise at FL370, another recording was made showing that
53,100 pounds of fuel had been used, with 29,300 pounds remaining. The TOD
was recorded as having occurred at 1942, at FL370. The fuel remaining gauge
indication and the sum of the individual fuel quantity gauge readings
25
recorded at this time were both 17,000 pounds. At a later point in the
flight, a fuel gauge sum reading of 14,600 pounds remaining was also
recorded. The time and altitude at which this observation was made were not
recorded.
The Weight and Balance and Load Summary form for AVA052 for the
flight from Medellin to New York completed by the Avianca Airlines' aircraft
dispatcher in Medellin showed a computed takeoff weight of 256,799 pounds and
a center of gravity of 28 percent MAC.
Data entered on the Fuel and Gross Weight Computation (FGC) form by
the flight engineer indicated that the weight of the airplane, at the time of
its departure from the gate at Medellin, was 258,800 pounds. Based upon a
takeoff gross weight of 257,300 pounds (258,800 minus 1,500) the forward and
aft C.G. limits would have remained unchanged.8
The Avianca flight dispatcher at Medellin stated that at the time

of AVA052's departure from runway 36, the runway was dry, and the outside air
temperature was 23O C (73O F). The wind was calm. Based upon these
conditions, the maximum allowable takeoff gross weight for runways 18 and 36
would have been 254,650 and 257,200 pounds, respectively.
Based on the conditions reported at the time of AVA052's takeoff

from Medellin, the following en route climb data factors were computed:
Brake release weight - 257,000 lbs.; International standard

atmosphere (ISA) plus 15O C, 4 engines, 3 turbocompressors;
Climb speed - 300 knots indicated to FL290; and 0.78 Mach
above FL290.9
Brake Release to 35,000 feet pressure altitude (PA):
Time: 27 minutes
Fuel: 9,393 lbs. t 10% overburn = 10,332 lbs.
Distance: 190 nautical miles
Average True Airspeed (AVTAS): 422 knotslo
80ata d e r i v e d f r o m t h e A v i a n c a 0-707 O p e r a t i o n s M a n u a l , L o a d i n g Section-

Terminal Airports, p. 24.50.122c, d a t e d O c t o b e r 2 7 , 1 9 8 6 .
‘S o u r c e : ZIP Operations Manual, pp. 19 and 20, dated March 22,

1983. Note: The information presented on pp. 19 and 20 did not contain
a n a d j u s t m e n t i n d e x f o r a t e m p e r a t u r e g r e a t e r t h a n I S A p l u s 15’C . The
a v e r a g e e n r o u t e c l i m b t e m p e r a t u r e uas I S A p l u s 22’ C .
“Source: ZIP Operations Manual, pp. 65 and 67, dated March 22,
1983. T h e follouing f a c t o r s w e r e c o n s i d e r e d : 0.81 Mach indicated, all
engines operating, 3 turbos, maximum cruise thrust limits, total air
temperature (TAT):
FL350 = ISA (-25 C) + 4 C (temp d i f f e r e n t i a l ) = - 2 1 C .

26
Brake Release to 37,000 feet PA:
Time: 32 minutes
Fuel: 10,492 lbs. t 10% overburn = 11,541 lbs.
Distance: 229 nautical miles
AVTAS: 428 knots
Computed fuel burn at cruise was determined for the following

conditions, including the meteorological conditions for the flight:
Aircraft Altitude Fuel Flow X 4 Plus 10%

Wt. in lbs. in feet lbs./hr lbs./hr.
250,000 35,000 11,816 12,998

230,000 35,000 11,080 12,188
220,000 37,000 10,424 11,466
210,000 37,000 10,068 11,075
Holding performance computations were made for the following

conditions:
Altitude Gross Wt. IAS Fuel flow Plus 10%
37,000 200,000 213 8,192 9,011

23,000 195,000 206 8,284 9,112
14,000 190,000 201 8,472 9,319
10,000 185,000 198 8,380 9,218
Long range cruise (inflight diversion) data was examined based upon
information obtained from the following sources:
a) The Fuel and Gross Weight Computations (FGC) form for

AVA052.
b) ATC recorded communications and radar data.
cl United States high and low altitude IFR en route

aeronautical charts.
Pan American World Airways, Inc., via a contractual agreement,

provided a dispatch service for Avianca Airlines' southbound flights from New
York. The Pan American flight planning computer provides for a lo-percent
overburn cushion for.all Avianca Airlines' B-707 flights.
FL370 = I S A ( - 2 8 C) + 3 C (temp d i f f e r e n t i a l ) = - 2 5 C .
Note: Temperatures at FL350 and FL370 are based on January 26, 1990,
002 u p p e r a i r d a t a i n t h e v i c i n i t y o f G r a n d Cayman.
27
The following data were computed by Pan American dispatch, using

the airline's flight planning computer. Distance computed is by airway
mileage rather than direct mileage. A zero fuel weight of 178,300 pounds was
assumed. The alternate fuel figure provides en route burn from the
destination (JFK) to the alternate, plus 30 minutes holding at 1,500 feet,
after a computed approach and missed approach at the alternate. En route
time to the alternate does not include 30 minutes holding. Again, a zero
knot wind is considered:
Alternate Distance Fuel Required Time in

Airoort from JFK in lbs minutes
Philadelphia 135 12,600 30
Bait/Wash
Boston 206
198 14,300
14,100 ;i
Dulles 256 15,300
Syracuse 227 14,700 t;
1.6.3 Fuel System
The B-707 uses a capacitance-type fuel quantity gauging system.

The system's components include fuel indicators and tank probes. The fuel
quantity indicator is a sealed, self-balancing, motor-driven instrument
containing a motor, pointer assembly, amplifier, bridge, circuit, and
adjustment potentiometer. A change in the fuel quantity of a tank causes a
change in the capacitance of the tank probe. The tank probe is one arm of a
capacitance bridge circuit. The voltage signal resulting from the unbalanced
bridge is amplified by a phase winding of a two-phase induction motor in the
indicator. The induction motor drives the wiper or a rebalancing
potentiometer in the proper direction to balance the bridge and, at the same
time, positions an indicator pointer to show the quantity of fuel remaining
in the tank.
Fuel is contained in seven tanks located within the wing and wing
center section. The reserve tanks and tanks No. 1, No. 2, No. 3, and No. 4
are integral to the wing structure. The center tank consists of seven
removable bladder cells within the wing center section, interconnected to two
integral wing root section tanks.
Fuel quantity indicators display usable fuel only. Maximum error

for each indicator is t/- 3 percent of full-scale reading. The quantity
indicators should read zero when all usable fuel has been consumed.
The fuel feed system consists of direct tank-to-engine lines

interconnected by crossfeed lines and a crossfeed manifold. Fuel is
supplied, under pressure, directly from each tank to its corresponding
engine by AC electric-powered fuel boost pumps. Fuel may be supplied to an
engine by an alternate method via the crossfeed manifold.
On February 15,' 1980, the Boeing Company, as a result of incidents

and other flight operations involving low-fuel conditions, issued operations
Manual Bulletin No. 80-l. The bulletin, which applied to all B-707
28
operators, was issued to " . ..provide information regarding flight operations

with low fuel quantity indications." The bulletin stated that the maximum
indicator error in the airplane's fuel quantity system "...should not exceed
plus or minus 3 percent of tank full scale reading."
The bulletin further stated that the minimum recommended fuel

quantity for landing:
. ..can best be determined by each operator due to the

differences in weather conditions, air traffic control,
communication, airline policy, etc.... However, to account
for a worst case main tank fuel quantity indicator error of
2,700 lbs. (1,200 kgs.) per main fuel tank, operators should
consider at least 7,000 lbs. (3,175 kgs.) as the minimum
indicated fuel quantity for landing. During any operation
with low fuel quantity, priority handling from ATC should be
requested."
On August 1, 1980, the Boeing Company published a revised version

of Bulletin No. 80-l. The revision contained much of the original language
but also stated the following:
Minimum fuel for landing can best be determined by each

operator due to differences in weather conditions, air traffic
control delays, airline policy, etc. However, operators
should consider the possible fuel quantity indicator error
shown... (plus or minus 3 percent of tank full scale reading)
when determining the minimum indicated fuel for landing. For
example, if the actual total of fuel in the four main tanks
for landing is 4,000 lbs. (1,814 kgs.) the total indicated
fuel could be as low as 1,300 lbs. (590 kgs.) or as high as
6,700 lbs. (3,039 kgs.). If any delay is anticipated due to
extended radar vectoring, etc., or if a go-around is likely,
then additional fuel for these contingencies should be added
to the planned fuel quantity for landing. During an operation
with very low fuel quantity, priority handling from ATC
should be requested.
Boeing Company personnel stated that the above bulletins were sent
to all B-707 operators.
“Postaccident testimony revealed that under FAA Air Traffic Control and
International Civi 1 Aviation Organization (ICAO) r e g u l a t ’i o n s , the word
01priority18
and the phrase “priority handling* have no prescribed meaning in
terms of required ATC controller action. Reference appendix C.
29
1.7 Meteorological Information
The 0700, January 25, 1990, surface weather map, prepared by the
National Weather Service, showed a deep low-pressure area centered over
northeastern Illinois, with a wavy stationary front extending eastward
through Indiana, and Ohio, and turning northeast in the vicinity of extreme
northeastern Maryland through Long Island, New York, eastern Massachusetts
and into southern Nova Scotia. Another stationary front extended northeast
from west central Georgia to the Virginia Capes, then east-northeast into the
Atlantic Ocean. A cold front extended south from the low through western
Indiana, Kentucky, and western Alabama into the Gulf of Mexico. Winds north
of the more northerly stationary front were north to northeasterly. Between
the fronts, winds were east to southeasterly. South of the southern
stationary front, winds were southerly. Skies were overcast, with rain over
all of the Mid-Atlantic states from southern Virginia to extreme southeastern
New York.
The 500-millibar map (about 18,000 feet) for 0700 showed a deep
trough extending south from the Manitoba-Ontario border through central
Minnesota and Iowa, western Missouri, and central Oklahoma and Texas. There
was a strong southeasterly flow over the eastern United States, with the jet
stream extending from central Arkansas through West Virginia, Pennsylvania,
and New England. Winds at the 500-millibar level in the vicinity of the
Mid-Atlantic states were southwesterly at 55 to 70 knots.
On the 2200 surface map (the accident occurred at about 2134), the
low was over northern Lake Huron with the occluded front extending east then
southeast from the low to the crest of the surface wave over northeastern
New York, becoming a cold front and extending south-southwest through eastern
Pennsylvania and into western Virginia. The northern stationary front
paralleled the cold front south-southwest into central Virginia turning back
north through the Chesapeake Bay and western New Jersey, and through
southeastern New York, west of New York City, before turning east-northeast
into the Atlantic immediately north of Cape Cod. A low was shown on the
front over western New Jersey. The southern stationary front was no longer
carried on the analysis. Winds in the warm sector south of the stationary
front were moderate to strong from the south. Conditions over the coastal
Mid-Atlantic states and New England remained overcast with rain.
The surface observation at JFK at 2100, approximately 34 minutes

prior to the accident, was as follows:
Type--special; ceiling-- indefinite 200 feet obscured;

visibility--l/4 mile; weather--light drizzle and fog; wind--
190° 21 knots; altimeter--29.69 inches; remarks--Runway 4R
visual range 2,200 feet variable 3,500 feet.
At 2135, the surface observation at JFK was as follows:
Type--special; ceiling--partial obscuration measured 300 feet

overcast; visibility 3/4 mile; weather--fog; wind--190°
20 knots; altimeter--29.70 inches; remarks--Runway 4R visual
30
range 5,500 feet variable 6,000 feet plus, fog obscuring 3/10
sky.
Regarding the filed alternate airport for AVA052, Boston-Logan

International Airport had the following observation at 1850:
Ceiling indefinite 300 feet obscured, visibility l/4 mile in

light rain and fog, wind 030° at 7 knots. Runway 4R visual
range 1,400 feet variable 2,400.
At 2050: ceiling--indefinite, zero feet obscured;

visibility--l/8 mile in light drizzle and fog; wind--loo0 at
9 knots. Runway 4R visual range 1,400 feet variable
1,600 feet.
This observation was issued about the same time (2046:24) that the
flightcrew of AVA052 advised NY ARTCC that they could no longer reach their
alternate.
The following are excerpts from pertinent International Airdrome

Forecasts (IAF's) for JFK and Boston Logan before the departure of AVA052
from Colombia:
IAF for JFK, issued January 25, 1990, at 0545, valid 0700
January 25, 1990, to 0700 January 26, 1990, in part:
Intermittently: 1200 to 1900: visibility 1 mile, moderate
rain, 8/8 stratus 800 feet. Gradually 1900 to 2000: Wind
170° 20 knots gusting to 30 knots, visibility 1 mile, light
rain, 8/8 stratus 800 feet.
January 25, 1990, to 0700 January 26, 1990, in part: Wind
160° 6 knots, visibility l-1/2 miles, light rain, 6/8 stratus
300 feet, 8/8 stratocumulus 2,000 feet.... Intermittently
0900 to 2000: visibility 1 mile, moderate rain, 7/8 stratus
400 feet.
January 25, 1990, to 1300 January 26, 1990, in part: Wind
160° 15 knots gusting to 25 knots, visibility 1 mile, light
rain, 8/8 stratus 400 feet.
IAF for Boston, issued 0500 January 25, 1990, valid 0700
Intermittently 1200 to 1800: visibility 3/4 mile, moderate
rain, 8/8 nimbostratus 500 feet. Gradually 1700 to 1800:
wind 180° 15 knots gusting to 25 knots, 8/8 nimbostratus
500 feet.
31
IAF for Boston, issued 1100 January 25, 1990, valid 1300
Gradually 1300 to 1400: wind 160° 15 knots, visibility
1 mile, light rain, 8/8 nimbostratus 800 feet.
The pertinent surface observations for JFK and Boston during the
departure and flight of AVA052 are contained in appendix E.
1.8 Aids to Navigation
There was no evidence that any of the navigational aids used by

AVA052 were out of service, or were not operating to specification, during
the evening of the accident flight.
1.9 Communications
All transmissions from the flight to U.S. air traffic controllers

were, in accordance with FAA regulations, in English. All intracockpit
communications during the last 40 minutes and 14 seconds, from 2053:09 to
2133:23, were recorded on the CVR tape in Spanish.
The CVR transcript, with Spanish to English translations, is

attached as appendix B.
1.9.1 Flight Following, Dispatching, and En Route Services
The airline did not incorporate flight following in its

dispatching procedures on flights to the United States. Although the
company's dispatcher and the flightcrew had the capability to communicate
between Colombia and the United States, it was normal that once the flight
had departed Colombia, no communications transpired between the flight and
the airline's dispatcher at Medellin.
Avianca Airlines had a contract with Dispatch Services,

Incorporated, a facility at Miami International Airport that provided a
dispatch function for numerous foreign flag air carriers operating within the
United States. The Dispatch Services dispatcher, on duty on the evening of
the flight, stated that he received a TELEXed departure message from Avianca
Airlines stating that AVA052 had departed Medellin. No departure time was
given. In anticipation of the flight contacting him as it passed the
vicinity of Miami en route north, the dispatcher obtained the latest weather
and air traffic information for JFK. He did not receive a call from the
flight and there was no record of communications between the Dispatch
Services dispatcher and AVA052. In addition, there were no records of
contacts by AVA052 with other flight services, such as flight service
stations VOLMET (transcribed international weather observation and
forecasts), EFAS (En Route Flight Advisory Service), or flight watch along
the route, to obtain weather or other information.
Avianca Airlines maintained an office at Miami International

Airport because Miami was a regular destination, as well as an en route stop
on Colombia-to-North America flights by the airline's B-727 airplanes. A
1
32
review of the go-day period prior to the January 25, 1990, accident found a
record of 28 Avianca B-727 airplanes making en route stops at Miami
International Airport. There was no record of en route refueling stops at
Miami International Airport by any of Avianca Airlines' four B-707 airplanes
during this same period.
An examination of the airline's records shows that out of an

average of four flights per week (three from Bogota and one from Medellin)
from January 6, 1989, through February 23, 1990, Avianca Airlines' flights
from Colombia to JFK diverted to an alternate airport a total of five times,
as follows:
January 6, 1989, a B-707 diverted to Boston
January 6, 1989, a B-727 diverted to Baltimore
September 16, 1989, a B-727 diverted to Washington
October 17, 1989, a B-727 diverted to Philadelphia
February 23, 1990, a B-727 diverted to Washington
1.10 Aerodrome Information
John F. Kennedy International Airport (JFK) is located in Jamaica,

Queens, New York, approximately 11 miles southeast of Manhattan. The airport
is categorized as "high density." Special air traffic rules in 14 CFR Part
93 apply. Prior reservation is required for arrival. In 1989, the airport
logged 483,367 operations (takeoffs or landings), of which 292,050 were
classified as air carrier.
JFK airport has five runways: 04 right/22 left, 04 left/22 right,

13 left/31 right, 13 right/31 left, and 14/32. Runway 14/32 is reserved for
short takeoff and landing (STOL) aircraft. The preferred ILS runways are
the 13/31 parallel runways.
On the evening of January 25, 1990, as a result of a wind from the

southwest, the active ILS runways were the parallel runways 22 left and
22 right. Runway 04 left/22 right is an 11,351-foot by 150-foot asphalt and
concrete runway, with a grooved surface. It had operating. high intensity
runway lights (HIRL) and centerline lights (CL). Runway visual range (RVR)
equipment was located at the threshold and rollout point at each end of the
runway. The minimum landing visibility for a straight-in precision ILS
approach to runway 22 right is 3/4 mile. The local weather conditions went
below 3/4 mile about 1547. For the remainder of the evening, all approaches
were made to, and landings were made on, runway 22 left. AVA052 was assigned
the ILS for runway 22 left.
Runway 04 right/22 left is an 8,400-foot by 150-foot asphalt

runway, with a grooved surface. On the evening of the accident, it had
operable HIRL, CL, a medium intensity approach lighting system with sequenced
flashing lights (MALSR), and touchdown zone lights (TDZ). RVR equipment was
33
located at the threshold, mid-length, and rollout point of each end of the
runway. The ILS and distance measuring equipment (DME) for the runway were
paired on frequency 110.9 megahertz. The minimum visibility for landing on
runway 22 left is l/2 mile, or an RVR of 2,000 feet for category D aircraft.
The "remarks" section of the Airport/Facility Directory (Northeast

United States) for JFK stated that temporary localizer needle aberrations may
be experienced on ILS approaches to runway 04 right or 22 left because of
heavy jet aircraft in the vicinity. Flights were requested to use caution
for possible radio interference or false instructions on the tower
frequencies.
On January 28, 1990, an inflight evaluation of the runway 22 left

ILS/DME approach was conducted by the Federal Aviation Administration. The
operation of the equipment was found satisfactory.
1.11 Flight Recorders
The flight data recorder (FDR), a Lockheed model 109, was removed
from the airplane wreckage by Safety Board investigators and brought to the
Safety Board's laboratory in Washington, D.C. Upon examination, it was found
that the recording medium had been expended at some point before the accident
flight, and the recording medium foil was taped down so that the recorder was
not operable at the time of the accident. No information was recorded by the
FDR during the accident flight.
The cockpit voice recorder (CVR) for AVA052 was a Collins model
642C-1. It was removed and brought to the Safety Board's audio laboratory.
The entire tape contained 40 minutes and 15 seconds of excellent quality
recording. A verbatim transcript (appendix B to this report) was prepared.
It is divided into three columns: one for the intracockpit communications,
mostly in Spanish; one for the English translation of the Spanish
communications; and one for radio transmissions between the flight and air
traffic control. Spanish-speaking Safety Board personnel participated in the
transcription and translation.
1.12 Wreckage and Impact Information
The airplane impacted on an approximately 24O upsloping hill.

(Figure 5 is a sketch showing a profile of the terrain and the airplane's
impact angle.) Based on ground scars left by the engines and airframe, the
entire fuselage, with the exception of the cockpit and forward cabin, came to
a stop within 21 to 25 feet after impact. (Figure 6 contains photographs
showing the wreckage site.)
The fuselage was found partially separated into three sections.

The cockpit and forward cabin had broken away from the rest of the fuselage
at the time of terrain impact and had continued to move over the crest of 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.
Approx. Apprax MISC.
Polnt Mp#on 6swElev. Meswuwnsnt TopElw. Notes
Sheared 17’ Hickory Tree m 61’ -133’ Measured

Sheared 16’Tulip Tree 6e -61’ -127
Sheared lo’Unk. Tree 79 -45’ -124’
Sheared 6’Maple Tree 72 -36’ -106’
Sheared Telephone Pole 67’ -16’ -103’
24’Oak Tree
1
200’
175’i I
1 1 Data Point 6
150’
125’
2 DP. 1
Data Point 5 DP. :
0 25’ 50’ 75’ 100’ 125’ 150’ 175’ 200 225’ 250’ 275’ 300’ 325’ 350’ 375’ 400’ 425’ 450’ 475
SCALE: 1” = 50’
Figure 5. --Terrain impact, AVA052.

35
I ’ 1
36
Figure 6b. --Wreckage site, AVA052.

37
The main fuselage had come to rest, upright, on the upslope of the
hill, on a heading of about 182O. The forward end of this section extended
over the crest of the slope.
The right horizontal stabilizer was found attached to the

empennage and was relatively undamaged. The left horizontal stabilizer was
found attached to the empennage but had fractured off into two pieces
approximately 4 feet outboard of the fuselage. Continuity was established to
the controls.
The vertical stabilizer was found intact. The rudder pedal

assemblies and all attached cockpit hardware had been bent and fractured, but
continuity was established from the cockpit rudder pedals and trim wheel to
the rudder assembly.
Both wings were found severely damaged. The port wing was found
fractured into three major pieces. The inboard piece extended from the wing
root to just inboard of the outboard engine. This piece had sheared off at
the root but was lying next to the fuselage and aft of its original attached
position. The next outboard wing section extended 2 feet across from the
inboard to the outboard fracture. The right wing exhibited the results of
several severe impacts on its leading edge. The outboard section of the
right wing had fractured away between the two engines. It was found lying
beside and aft of the inboard section. The inboard section, still attached
to the fuselage at the wing root, came to rest against trees near the top of
the slope. All attached leading edge flaps and slats were in the extended
position.
The flaps were measured at a 14O setting. All trailing edge

surfaces were found either still attached to the wing, in their proper
positions, or lying under the wing. There was no evidence of any preimpact
failure within the flap system.
Inboard and outboard ailerons, on both the port and starboard

wings, were found still intact. Continuity was found from the cockpit to all
aileron controls. Inspection of the aileron system found that roll control
through outboard aileron operation was available, consistent with deployment
of the trailing edge flaps.
The No. 1 engine was found still attached to the fractured section
of the left wing. The No. 2 engine was found still attached to the inboard
fractured section of the left wing.
The No. 3 engine was found lying at 7 o'clock, relative to its

proper position on the starboard wing. It was separated at the engine mounts
and the inlet was embedded in the hill. The No. 4 engine was found separated
from the pylon at the engine mounts and was lying 25 feet forward of its
initial point of impact. Its damaged right side cowling was lying nearby.
There was no evidence of inflight or postimpact scorching or arcing

within the electrical system and no evidence of fire or fuel odor anywhere in
1
38
the airplane. Examination of all four engines revealed no evidence of

rotation or power at impact.
All four of the main fuel tanks had been punctured by trees at
impact. Access doors were removed from the fuel tanks in order to inspect
for the presence of fuel. A small quantity (less than 5 gallons) was found
in the aft portion of the No. 4 tank. A cotton wiping rag, measuring
approximately 5 by 8 inches, was found near the aft boost pump, in the No. 4
tank. During removal of the No. 4 main tank boost pump, l-1/2 to 2 gallons
of fuel were drained from the pump cavity. The fuel dump chutes were in the
stowed position.
The cockpit fuel gauges were removed for testing. (See details in
section 1.16 of this report.)
1.13 Medical and Pathological Information
All three flight crewmembers were fatally injured at impact. The

pilot and first officer sustained severe head injuries. The second officer
sustained severe chest injuries and multiple fractures.
Toxicological samples of the flightcrew's remains were negative for

alcohol and drugs, with the exception of one laboratory which found very low
levels of ethanol and E-butanol in a liver sample. This sample was
determined to have been contaminated with external material.
There was no evidence that any of the three flight crewmembers was
not rested prior to departure. There was no evidence of recent, unusual
stress upon any crewmember.
Toxicological samples were obtained by the FAA on five of the ATC

specialists who controlled AVA052 in the latter stages of its flight. Those
tested included two controllers from the New York ARTCC, two from the New
York TRACON, and the local controller at JFK tower. Under DOT regulations
existing at that time, the FAA was not required to provide the results of
these tests to the Safety Board. Board investigators requested the results
of these tests directly from the controllers but they declined. They also
declined to submit to Safety Board requests for separate toxicological
testing. No evidence was found to indicate that controller fitness for duty
was a factor in the accident.
1.14 Fire
There was no fire.

39
1.15 Survival Aspects
1.15.1 Rescue
After the crash, a large rescue effort was quickly mobilized.

Local residents, who were first on the scene, called police, fire, and
emergency telephone numbers. The response came from several neighboring
communities and services.
There was a narrow, blacktopped residential road traversing the

slope of the hill at the point where the airplane's empennage came to rest.
Another branch of the residential road that passed by a residence was struck
by the airplane. Both of these narrow roads combined into a single
residential road, which continued outbound to the highway and the town of
Cove Neck.
Rescuers were restricted by the single residential road upon which

to gain access to the crash site. This problem, combined with the number of
responding agencies, resulted in a traffic jam on the road between the
accident site and the highway. Despite quick and professional efforts to
get appropriate vehicles into and out of the site, more rescuers were
available than could be used, and a speedy means to move survivors became the
priority. Nassau County Police helicopters were brought in and, operating
from an improvised landing site in the backyard of a residence located below
the accident site, flew out many of the injured.
1.15.2 Location of Crew and Passengers in Relation to Injuries
Interior furnishings, consisting of the galley, seat units, seat

belts, overhead bins, decorative panels and floor structure from the
cockpit/forward fuselage section, were found scattered along the wreckage
path between the separated forward section of the cabin and cockpit, back to
and into the fractured opening of the second section of 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 cockpit and forward cabin
section.
The interior of the cockpit was found substantially damaged. Four

of the five cockpit seats (the three seats occupied by the flightcrew, as
well as one of the two observer jump seats, both of which were unoccupied)
were lying outside the cockpit.
The captain's seat was separated from the lower leg attachments to
the base structure of the seat. The seat pan, back and adjustment mechanisms
were found generally intact. There were no shoulder straps or inertial reel
installed on the pilot's seat. The base of the seat was attached to a 3-by
4-foot section of the cockpit's flight deck. That section of floor was the
largest section of the floor from within the cockpit found intact. The
floor, although separated in several places, was flat without significant
deformation.
40
The first officer's seat was substantially damaged. The seat back
was separated from the seat frame and was not located. The seat adjustment
mechanism system was intact. The left and right sides of the lap belt and
rotary type release buckle were on the seat and were operational. There were
no shoulder straps and no inertial reel for shoulder straps with the seat
assembly.
The flight engineer's pedestal-type seat was lyi ng outside the

cockpit. The seat was equipped with a four-point restraint system, and the
inertia reel for the single shoulder harness was damaged but still attached.
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 opening. There
was a fracture of the longitudinal floor track-beam, 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 legs of 16 seat assemblies
remained attached to the floor track in the overwing section. The
outboardlegs of these assemblies were fractured at the floor track. These
seats were found outside the cabin and forward of the overwing section.
The aft cabin section was open at its forward end. Most of the
seats in this section were found separated from their floor tracks. The
floor panels were displaced, the aft galley and lavatories were displaced,
and food from the galley was scattered throughout this section.
Most cabin doors were found opened, including the main boarding
door (L-l), the forward galley door (R-l) and the aft galley door (R-4). The
left forward overwing emergency exit hatch was found in place and could not
be opened because of fuselage distortion.
The emergency evacuation slide packs for doors L-l and R-l were in
place and relatively undamaged. Evacuation slide inflation bottles remained
partially pressurized. The emergency slide pack for the rear cabin entrance
(L-4) was in a significantly damaged area of the fuselage. The rear g;il;;
slide pack (R-4) was missing from the door and could not be located.
were no girt bars found for any of the slide assemblies.
The left aft overwing emergency exit hatch could not be located.
However, it was reported by rescuers that they had removed this hatch, as
well as the two overwing hatches on the right side of the cabin. They
reported no difficulty in removing these hatches.
The aft section of the fuselage had rolled slightly to the left and
came to rest on the lower one-third of the L-4 aft cabin entry door,
preventing the door from opening. The damage to the inside of the cabin was
extensive in this area.
41
1.16 Tests and Research
The fuel quantity gauges for tanks No. 2 and No. 3, and the fuel
totalizer gauge were removed, at the site, from the flight engineer's panel.
Under Safety Board supervision, they were tested at the facility of the gauge
manufacturer.
All three of these gauges were manufactured by Honeywell Military

Products Division, Minneapolis, Minnesota. The manufacturer's records
indicate that none of the three gauges had been returned during the service
period. All three of the gauges were of the rotating pointer-type design.
The gauges are AC powered, and, unless otherwise affected, retain their
indications when electrical power is stopped.
Gauges installed for the No. 2 and No. 3 main fuel tanks had a
maximum indicating capacity reading of 29,000 pounds. The larger pointer on
the gauge indicates increments of 1,000 pounds. The smaller pointer is
graduated in 100 pound increments.
The fuel quantity totalizer gauge has a maximum capacity reading of

170,000 pounds. The larger pointer indicates increments of 10,000 pounds.
The small pointer is graduated in 1,000 pound increments. The totalizer
gauge sums capacitance inputs from the probes mounted in each fuel tank and
indicates total fuel available. It operates independently of the individual
fuel tank quantity indicators.
The fuel quantity gauge for the No. 2 main tank was badly damaged
from impact forces. The glass covering the face of the gauge was missing.
The gauge indicated 2,300 pounds when examined at the accident site. It was
found to be connected to its proper electrical connector in the flight
engineer's panel. Both of the indicator needles were found intact and
appeared undamaged; however, the larger needle on the gauge could easily be
rotated, and its reading was considered unreliable.
Resistance measurements were recorded across the balancing

potentiometer inside the No. 2 main tank gauge. Calculations show that the
gauge read approximately 2.5 percent of total at the time of power
interruption. Using 29,000 pounds as the gauge reading with a full No. 2
fuel tank, extrapolation yielded an indication of approximately 725 pounds at
the time of loss of electrical power. This estimate was corroborated by a
laboratory examination of the position of the gauge's internal gears.
The fuel gauge installed to provide the No. 3 main tank quantity
indication was found badly damaged. The glass covering the face of the gauge
was missing. The gauge read 2,300 pounds. It was connected to its proper
electrical connector in the flight engineer's panel. Both of the needles
were intact and appeared undamaged; however the larger needle on the gauge
could easily be rotated. On-site readings were considered unreliable.
Internal components of the No. 3 main tank, gauge appeared

undamaged. Resistance measurements were recorded across the balancing
potentiometer inside the gauge. Calculations showed that the gauge read
I
42
approximately I.0 percent of total at the time of electrical power

interruption. Extrapolating from a 29,000 pounds gauge indication, with a
full No. 3 main fuel tank, 1.0 percent would equate to an indicated fuel
quantity on the gauge of approximately 290 pounds. The reliability of the
290 pounds extrapolation was confirmed by examining internal gear
positioning in the gauge.
The fuel totalizer gauge, installed in the flight engineer's

panel, was relatively undamaged. The glass covering the face was intact,
with a crack running across the lower corner. At the accident site, the
gauge read 1,300 pounds. There was a small dent in the forward section of
the gauge case.
All internal components of the fuel totalizer gauge appeared

undamaged. Resistance measurements were recorded across the balancing
potentiometer. Calculations show that the gauge read approximately
1.6 percent of total at the time that electrical power was no longer
received. With 170,000 pounds as a "total fuel" gauge reading, 1.6 percent
equates to approximately 2,700 pounds as the total indicated fuel aboard at
the time that electrical power was lost. With negligible fuel found in the
tanks after impact, 2,700 pounds indicated, or 1.6 percent, falls within the
limits of the plus or minus 3 percent gauge error. As with the No. 2 and
No. 3 main fuel tank gauges, this estimate was corroborated by internal gauge
gear positions.
1.17 Additional Information
1.17.1 Airline Procedures
Avianca Airlines is owned and controlled by citizens of the

Republic of Colombia. The airline has provided regular scheduled services
between Colombia and the United States since 1946. At the time of the
accident, the airline was conducting four scheduled B-707 flights per week
from Colombia to New York City. Three of these flights originated in Bogota
and one in Medellin.
As of March 1, 1990, Avianca Airlines was one of 246 airlines

granted foreign air carrier authority by the U.S. Department of
Transportation (DOT), under section 402 of the Federal Aviation Act of 1958,
as amended.
Regarding flight following, Avianca Airlines' flights originating

in Colombia and destined for the United States have been required to be
conducted under the regulatory provisions of 14 CFR Part 129. This
regulation requires that authorized foreign air carriers operating within the
United States conduct their operations in accordance with the operations
specifications issued by the Federal Aviation Administration and with the
standards and recommended practices contained in Annex 6, Part 1, as
promulgated by ICAO (International Civil Aviation Organization).
43
14 CFR Part 129, and the operations specifications issued to

Avianca Airlines, do not address flight following. ICAO Annex 6, Part 1,
Chapter 4, paragraph 2 (4.2), directed the airline to establish and maintain
a method of supervision of flight operations approved by the state of the
operator (Colombian Civil Aviation Authority). Chapter 4, paragraph 6.1
states, in part, that:
A flight operations officer, when employed in conjunction with

a method of flight supervision in accordance with 4.2, shall:
cl furnish the pilot-in-command while in flight,

by appropriate means, information which may be
necessary for the safe conduct of the flight.
Regarding contracted dispatching services, as noted earlier,

Dispatch Services Incorporated maintained a facility in Miami, Florida,
available on frequency 130.4 megahertz. The contract provided for dispatch
services for flights northbound from Colombia to the United States. AVA052
did not make contact with this service.
Under a contractual agreement, Pan American World Airways, Inc.,

provided dispatch services, including flight following, for Avianca
Airlines' flights southbound from New York to Colombia. A Pan American
manager told Safety Board investigators that there was nothing to prevent a
northbound flight from contacting Pan American World Airways, Inc., dispatch
for assistance. He also stated that such contact has rarely occurred. The
manager stated that, if requested, Pan American dispatch would have provided
AVA052 the same assistance it gives to Pan American flights, including the
latest updates on weather for the destination and alternate airports, and
diversion fuel figures for the alternates, based upon fuel remaining
information provided by the flightcrew.
1.17.2 Air Traffic Control Facilities and Procedures
The Washington ARTCC, located in Leesburg, Virginia, is a level 3

facility (the highest level of traffic intensity for an ATC facility),
providing services 24 hours a day. The Washington ARTCC airspace consists of
approximately 150,000 square miles in nine states. It is bounded on the
north by New York and Cleveland ARTCCs. There are 44 sectors supported by
seven en route radar sites. There are four terminals within the Washington
ARTCC airspace, which support significant hub activity for one or more major
airlines. Traffic flows within the Washington ARTCC are predominantly of a
northeast/southwest orientation, with the majority of the aircraft in a
transitional mode, climbing or descending. There are 13 approach controls
and 8 military bases situated within the airspace.
The NY ARTCC, located at the MacArthur Airport, Ronkonkoma, New

York, is a level 3 en route ATC facility, which provides services 24 hours a
day. The area of control responsibility extends over seven states,
totalling more than 41,000 square miles of domestic airspace and 2.5 million
square miles of oceanic airspace. The oceanic area handles all the traffic
44
over the North Atlantic, from the Caribbean area, South America, Southern
Europe, and Africa.
The R67 and H67 operating positions are located in area "E" of the
NY ARTCC. The facility was authorized 308 full performance level
controllers and traffic management coordinators, at the time of the accident,
of which 186 were on board. The NY ARTCC has been identified as a critically
staffed facility. Employees have been granted a 20-percent pay differential.
The NY TRACON, located in Westbury, New York, is a level 5

terminal facility (the highest level of traffic intensity for a terminal),
providing services 24 hours a day. The NY TRACON controls all air traffic
for the three major New York Metropolitan Area airports: JFK, LaGuardia, and
Newark. It also controls numerous heliports and about 35 other airports,
which are located within an area of New York, extending 55 nmi to the
southwest and 100 nmi to the northeast of the World Trade Center in
Manhattan.
The NY TRACON controls the above airports with the use of four
radar sensors, which are remotely stationed at JFK, Newark, Long Island
MacArthur (Islip Airport) and Westchester County airports. Responsibility
for the control of air traffic over these areas is divided among five areas:
JFK, LaGuardia, Newark, Islip, and Liberty. In addition to the three
metropolitan airports, there are more than 37 airports in three states (New
York, New Jersey, and Connecticut) under the control of NY TRACON.
The Final Vector and CAMRN/LENDY positions of operation are

located in the JFK area of the NY TRACON. The NY TRACON is authorized 214
full performance level controllers and traffic management coordinators, of
which 113 were on board. It has been identified as a critically staffed
facility. Employees have been granted a 20-percent pay differential.
The JFK tower is a level 4 limited radar tower cab ATC facility,
providing services 24 hours a day. The airport is located within the
delegated airspace of the NY TRACON, and the tower receives approach control
services from the Kennedy sector of the NY TRACON. The JFK tower is at JFK
Airport, which is in Jamaica, Queens, New York. The facility is staffed with
15 full performance level controllers and 12 controllers in training.
1.17.3 - Traffic Management
The Central Flow Control Facility (CFCF) is located on the sixth

floor of FAA headquarters, 800 Independence Avenue, S.W., Washington, D.C.
The function of the CFCF is to manage the airspace of the National Airspace
System, consistent with demand, to ensure that the number of airplanes that
flow throughout the system does not exceed the capacity of the airports and
the sectors en route. CFCF operates 24 hours a day.
The CFCF has eight traffic management operating positions,

including the watch supervisor's position. Each operating position is
equipped with a computerized communications system that links all ATC
facilities. The facility is also equipped with the Aircraft Situation
45
Display (ASD), a computer system that receives radar track data from all
ARTCCs, and presents visual situation displays by computer screen. The
purpose of the ASD is to monitor the flow control programs initiated by the
CFCF and the traffic management specialists. The facility is also staffed
with specialists from the National Weather Service. Their duty is to
provide weather forecasts, weather sequences, and any weather data that may
have a significant impact on the National Airspace System.
The Safety Board was informed that on the evening of January 25,
1990, the CFCF was staffed with seven or eight traffic management
specialists. There were 10 traffic management (flow control) programs in
effect, a higher number of programs than normal. A traffic management
program was in effect for flights scheduled to arrive at the JFK airport
after 1400. The evening shift supervisor believed that the program had been
implemented between 0900 and 1000. The purpose of the program was to reduce
the number of flights arriving at JFK each hour after the start of the
program because of the poor weather conditions that were forecast to affect
all New York Metropolitan Area airports throughout the day.
Normally, at the end of a shift, a traffic management specialist

can retrieve a Verification and Analysis Report from the CFCF computer in
order to determine the effectiveness of a given program. However, on
January 25, 1990, a report for the JFK program was not retrievable because of
computer problems.
FAA order 7210.47A, "Traffic Management System," defines the

responsibilities, procedures, and methods of application for the Traffic
Management System.
The guidelines for the operation of the Traffic Management System

are contained in FAA order 7210.47A, Traffic Management System.
Paragraph 2-51 describes coordination requirements for the CFCF

specialists. Paragraph 2-51 states: "CFCF TMC (traffic management
coordinators) shall:
1. Work closely with the CFWSU (central flow weather service

unit) to insure the receipt of timely weather forecasts,
observed terminal weather sequences, and any weather data
which may have a significant impact on the NAS (national
airspace system).
2. Work directly with the center TMU and terminals in the

day-to-day operations. Resolve immediate operational
traffic management disagreements between facilities.
3. Initiate telephone conferences with user, as necessary,

to obtain user input and to provide operational delay
information, as well as other significant events
affecting the NAS.
I
46
Paragraph 3-29 and Appendix A, paragraph A-7, describe the CFCF

specialists' procedures for monitoring a ground delay program. Paragraph
3-29 states 'CFCF Monitoring Procedures:"
1. Continue ongoing coordination with affected facilities to

determine if capacity and demand have been equalized.
2. Obtain arrival and departure counts from impacted

facility(s), as appropriate.
3. Obtain arrival and departure delay information.
4. Utilize the aircraft situation display (ASD) to monitor

flow patterns, obtain estimated arrival counts, or
airborne delay estimates.
5. Adjust or cancel program, as appropriate, and transmit

CFCF advisory.
Appendix A, paragraph A-7, states, in part, "After the

implementation of a program, factors affecting the forecasts [of demand and
capacity] are monitored for change, as are the actual demand and capacity as
the program develops. The program may need to be modified if monitoring
reveals that any factor affecting forecast demand or capacity has changed
significantly or if the program is not proceeding as forecast."
Paragraph 3-2(3f), requires the tower TMC to "forward the total

number of hourly IFR arrivals and departures to CFCF as soon as possible
after each hour, in order that timely program adjustments may be made."
A detailed chronology of the events recorded for JFK's FAA Ground

Delay Program on January 25, 1990, is attached as appendix C.
1.17.4 Expect Further Clearance (EFC) Times
According to FAA Order 7110.65F, paragraph 4-50, states: "when it

is necessary to clear an aircraft to a fix other than the destination
airport, issue the following: a clearance limit, holding instructions, and
an EFC., An EFC is not required if no delay is expected.' The air traffic
controller is also instructed: "when additional holding is expected at any
other fix in your facility's area, state the fix and your best estimate of
the additional delay. When more than one fix is involved, state the total
additional en route delay (omit specific fixes)." A note contained in
paragraph 4-50 states: "additional delay information is not used to
determine pilot action in the event of two-way communications failure.
Pilots are expected to predicate their actions on the provisions of FAR
91.127.”
Air traffic controllers are expected to determine an accurate

estimate of the delay in order to inform the pilot. Controllers determine
this information based upon the information that they receive from various
sources, traffic management unit personnel, supervisors, other controllers,
47
other air traffic control facilities and, occasionally airport management

personnel. However, a controller usually receives an estimate from the
controller responsible for the next sector of airspace into which an aircraft
is expected to fly.
If a controller is holding aircraft for the next sector, the

controller responsible for the next sector usually informs the controller in
whose sector the aircraft are being held the amount of time required before
he can accept another aircraft. If the traffic situation allows, he usually
informs the controller that he will accept aircraft at specific intervals,
preventing the necessity of coordinating each aircraft. If a situation
arises that changes the amount of delay for an aircraft, the controller must
issue amended EFCs as soon as he or she determines the amount of additional
delay.
A second note in paragraph 4-50 further explains to controllers:

when holding is necessary, the phrase "delay indefinite" should be used when
an accurate estimate of the delay time and the reason for the delay cannot
immediately be determined; i.e., disabled aircraft on the runway, terminal or
center sector saturation, weather below landing minimums, etc. In any event,
every attempt should be made to provide the pilot with the best possible
estimate of his delay time and the reason for the delay.
Controllers/supervisors should consult, as appropriate, with personnel (other
sectors, weather forecasters, the airport management, other facilities, etc.)
who can best provide this information.
Although the controller is instructed to inform a pilot that a

delay is indefinite, the controller is also responsible for issuing the pilot
an EFC.
An EFC issued under an "indefinite delay" situation would provide a

pilot with lost communications information but little else, other than a
controller's "best possible estimate of his delay time."
1.17.5 Air Traffic Control of Emergencies
FAA order 7110.65F, "Air Traffic Control," Chapter 9, provides

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.
. After the controller has determined the extent of the emergency, he

required to obtain enough information to handle the emergency
iitelligently. The controller is required to base his decisions regarding
the type of assistance on the pilot's determination because the pilot is
authorized by FAR 91 to determine a course of action. When an emergency has
been declared by a pilot, or when an air traffic controller has determined
that an emergency exists, the controller is required to provide maximum
assistance. The controller is expected to select and pursue a course of
48
action that appears to be most appropriate under the circumstances and that
most nearly conforms to the instructions in the ATC Handbook. It is the
responsibility of the controller to forward to pertinent facilities and
agencies any information concerning the emergency aircraft.
1.17.6 Regulations and Airline Policies on Weather and Fuel
The 14 CFR 121.625, "Alternate Airport Weather Minimums," notes the

minimum weather conditions for filing an airport as an alternate in IFR
conditions as:
No person may list an airport as an alternate airport in the

flight release unless the appropriate weather reports or
forecasts, or any combination thereof, indicate that the
weather conditions will be at or above the alternate weather
minimums specified in the certificate holder's operations
specifications for that airport when the flight arrives.
The Operations Specifications issued to Avianca Airlines by the FAA

give the following criteria for the selection of alternate airports:
. ..the standard weather minima applicable to alternate

airports designated for dispatch or flight release purposes
are 600-2 [ceiling in feet and visibility in statute miles] at
airports served by precision approach procedures. However,
when an airport is served by two operative navigational
facilities, each providing an approved straight-in approach to
a suitable but different runway, alternate minima of 200-l/2
above the lower regular airport landing minima of the two
approaches, or 400-l (whichever is higher), are authorized
provided appropriate weather reports, or forecasts, or any
combination thereof, indicate that the weather conditions
will, at the time the flight arrives at the alternate
airport, permit a straight-in instrument approach.
The airline's Policy Manual also states that when an afternoon or

evening takeoff with a night landing is scheduled, the requirements for the
destination, alternate or supplementary airports are a l,OOO-foot ceiling
and 10 kilometers (6.2 statute miles) visibility.
The Avianca Route Manual contains the following information

relevant to low fuel state:
Pilot
(1) Advise ATC of your minimum fuel status when your fuel
supply has reached a state where, reaching
destination, you cannot accept any undue deyyyn.
(2) Be aware this is not an emergency situation but merely an

advisory that indicates an emergency situation is
possible should any undue delay occur.
49
(3) Be aware a minimum fuel advisory does not imply a need

for traffic priority.
Foreign and U.S. domestic air carriers, which conduct international

operations, are respectively guided regarding flight planning by relevant
sections of Annex 6, Part 1, Chapter 4, of the International Civil Aviation
Organization (ICAO), and 14 CFR Part 121 - Certification and Operations:
Domestic, Flag, and Supplemental Air Carriers and Commercial Operators of
Large Aircraft.
Regarding fuel supply, 14 CFR 121.645 states, in part:
. ..no person may release for flight or takeoff a turbine-

engine powered airplane (other than a turbo-propeller powered
airplane) unless, considering wind and other weather
conditions expected, it has enough fuel:
(1) To fly to and land at the airport to which it is

released;
(2) After that, to fly for a period of 10 percent of the

total time required to fly from the airport of
departure to, and land at, the airport to which it
was released;
(3) After that, to fly to and land at the most distant

alternate airport specified in the flight release,
if an alternate is required; and
(4) After that, to fly for 30 minutes at holding speed

at 1,500 feet above the alternate airport...under
standard temperature conditions.
14 CFR 121.621 "Alternate Airport for Destination: Flag Air

Carriers," states in part,
(a) No person may dispatch an airplane under IFR or over-the-

top unless he lists at least one alternate airport for
each destination airport in the dispatch release,
unless... [exceptions not applicable].
(b) For the purposes of paragraph (a) of this section, the

weather conditions at the alternate airport must meet the
requirements of the air carrier's operations
specifications.
(c) No person may dispatch a flight unless he lists each

required alternate airport in the dispatch release.
1
50
Excerpt of Annex 6, Part 1, Chapter 4 (ICAO):
4.3.6.1 All aeroplanes. A flight shall not be commenced unless,

taking into account both the meterological conditions and any delays that are
expected in flight, the aeroplane carries sufficient fuel and oil to ensure
that it can safely complete the flight. In addition, a reserve shall be
carried to provide for contingencies.
4.3.6.3 Aeroplanes equipped with turbo-jet engines. The fuel and

oil carried in order to comply with 4.3.6.1 shall, in the case of turbo-jet
aeroplanes, be at least the amount sufficient to allow the aeroplanes:
(continued with 4.3.6.3.2)
4.3.6.3.2 When an alternate aerodrome is required:
(a) to fly to and execute an approach, and a missed approach,

at the aerodrome to which the flight is planned, and
thereafter:
1) to fly to the alternate aerodrome specified in

the flight plan; and then
2) to fly for 30 minutes at holding speed at 450 m

(1,500 ft.) above the alternate aerodrome under
standard temperature conditions, and approach
and land; and
3) to have an additional amount of fuel sufficient

to provide for the increased consumption on the
occurrence of any of the potential
contingencies specified by the operator to the
satisfaction of the State of the Operator.
(b) to fly to the alternate aerodrome via any predetermined

point and thereafter for 30 minutes at 450 m (1,500 ft.)
above the alternate aerodrome, due provisions having been
made for an additional amount of fuel sufficient to
provide for the increased consumption on the occurrence
of any of the potential contingencies specified by the
operator to the satisfaction of the State of the
Operator; provided that fuel shall not be less than the
amount of fuel required to fly to the aerodrome to which
the flight is planned and thereafter for two hours at
normal cruise consumption.
4.3.6.4 In computing the fuel and oil requi red in 4.3.6.1, at

least the following shall be considered:
4 meteorological conditions forecast;
b) expected air traffic control routings and traffic delays;

51
a one instrument approach at the destination aerodrome,

including a missed approach;
4 the procedures prescribed in the Operations Manual for

loss of pressurization, where applicable, or failure of
one power unit while en route; and
e) any other conditions that may delay the landing of the

aeroplane or increase fuel and/or oil consumption.
2.0 ANALYSIS
2.1 General
The evidence confirmed that this accident occurred when the

airplane's engines lost power from fuel exhaustion while the flight was
maneuvering for a second instrument approach to JFK. Significant evidence
was information contained on the CVR and examination of the airplane's
wreckage. There was an absence of fuel odor at the accident site, and no
fire erupted during the impact. The only fuel found in the airplane was
residual unusable fuel. There was no rotational damage to any of the four
engines from impact forces, indicating that they had ceased operation before
ground impact. In addition, the investigation found no engine or fuel system
component malfunctions, including any that could have caused a premature
exhaustion of fuel or a loss of fuel supply to the engine.
The investigation revealed that the flightcrew had received the

appropriate flight and ground training in the B-707 and that they possessed
the appropriate flight and medical certification required by the DAAC of
Colombia. Further, they had sufficient previous experience in conducting
B-707 flights from Colombia to JFK.
The investigation revealed that the airplane departed Medellin,

Colombia, with sufficient fuel to fly to its destination. Its scheduled
flight time was 4 hours 40 minutes. However, the airplane crashed 6 hours
and 26 minutes after takeoff. Its flight plan called for a "required" fuel
load of 72,430 pounds of fuel for the flight, which included fuel to JFK,
reserve fuel, fuel to the alternate, and holding fuel, for a total of 6 hours
and 8 minutes of flight.
The evidence revealed that an additional amount of fuel was loaded

aboard AVA052 above the required load. That amount was about 6,070 pounds,
bringing the total planned load to about 80,500 pounds for takeoff at
Medellin. The Safety Board believes that the actual fuel aboard the flight
at takeoff from Medellin was about 80,500 pounds, based on various documents
available and the fuel figure notations made by the flight engineer during
the flight. Because of differences in the fuel numbers on some of these
documents, this value could be in error either way by about 1,000 pounds;
nevertheless, AVA052 had sufficient fuel to complete the scheduled flight, as
well as to meet other prescribed IFR fuel requirements. For example, there
was sufficient fuel to fly the scheduled route to the destination airport
52
(JFK), execute a missed approach, and fly to the alternate airport (Boston).
However, Boston was forecast to be below IFR alternate minimums when AVA052's
flight plan was filed, and the actual weather there deteriorated further
while the flight was en route.
The investigation revealed inadequacies in the dispatching

services of AVA052 from Medellin, as well as deficiencies in the performance
of the flightcrew of AVA052 while en route and during the attempted landing
approach at JFK. The investigation also revealed deficiencies in the ATC
handling of AVA052. Consequently, the analysis of this accident focused on
the planning for the flight, the flightcrew's performance during the flight,
and the air traffic controllers' performance during the flight. The analysis
also included the issues related to occupant survivability.
2.2 Flight Planning
Avianca Airlines had a dispatcher at Bogota and at Medellin, but

the Safety Board found inadequacies in the dispatching services of AVA052.
The weather data provided to the flightcrew of AVA052 before

departure from Medellin was 9 to 10 hours old. These weather data, as well
as weather data that was current at the time of departure, showed that all
the planned alternates for the accident flight were forecast to be below the
minima specified for an alternate airport at the time of AVA052's arrival
near JFK. This forecast included the filed alternate airport--Boston Logan
International Airport (BOS). Airports such as Syracuse and Buffalo were
forecast to have legal alternate weather; however, these airports were not
listed in the documents provided to the flightcrew. Both the outdated and
current weather data showed that JFK was forecast to have low ceilings and
restricted visibility near or below those authorized for AVA052 to execute an
approach.
Evidence provided by Avianca Airlines' personnel and testimony by

its management personnel indicated that BOS was listed as an alternate for
this flight because it was part of a computer-generated flight plan for all
flights to JFK, without regard for forecast weather. Avianca personnel
stated that one reason for choosing BOS as an alternate to JFK was that it
was a reasonable distance from JfK and therefore "conservative" for fuel
planning purposes, allowing the use of closer alternates. The Safety Board
believes that the listing of an alternate airport with forecast weather below
minima illustrates inadequate dispatching services provided by the airline
for AVA052. The flightcrew of AVA052 should also have been aware of the
requirements for weather minima for this flight.
The Safety Board was unable to establish whether the dispatcher for
AVA052 had received training in meteorology or navigation. The dispatch
function in airline operations is an important part of the safety of
operations. The dispatcher for an airline flight shares the responsibility
for proper flight planning, including fuel loading, weight and balance
calculations, and appropriate weather information. The ,Safety Board is
concerned that AVA052 was not provided adequate dispatch services on the day
53
of its departure from Medellin. It believes that these deficiencies may

have affected the performance of the flightcrew during this flight.
The weather information provided by dispatch at Medellin was not

the latest weather available. Also, there is no record that the flightcrew
used available resources to obtain updated weather and traffic information
during the en route phase of the flight. Whatever the reasons for these
oversights, these factors prevented the flightcrew from being properly
prepared for the flight.
With regard to fuel planning, Avianca personnel stated that the

airline elected to follow U.S. requirements (14 CFR 121.645) because they
are more stringent than ICAO-recommended procedures. The U.S. regulations
and ICAO standards differ primarily in the language used to compute the
amount of fuel required for potential contingencies. 14 CFR Part 121.645
requires, in part, "(2) After that, to fly for a period of 10 percent of the
total time required to fly from the airport of departure to, and land at, the
airport to which it was released." (3) After that, to fly to and land at the
most distant alternate airport specified in the flight release, fan alternate
is required, and (4) After that, to fly for 30 minutes at holding speed at
1,500 feet above the alternate airport...." The ICAO provisions on this
point are more general, requiring an "additional amount" of fuel that is
satisfactory to the governing agency. The DAAC of Colombia supported the
airline's use of the U.S. regulation.
The Safety Board found several deficiencies in the flight plan

issued to and used by the flightcrew of AVA052. It did not reflect the most
current upper air data, or the actual gross weight of the airplane upon
departure from Medellin. The reserve fuel stipulated in the flight plan out
of Medellin did not account for the possibility of extensive en route and
landing delays at JFK or at the alternate because of weather and air traffic
conditions. If a new flight plan or a revision to the existing flight plan
had been requested by the dispatcher and the captain before AVA052's
departure, the flightcrew might have anticipated more extensive delays in the
JFK area and been more prone to fuel state awareness and flight planning en
route.
Upon takeoff at Medellin, the gross weight of the airplane was

more than 4,000 pounds above that indicated on the flight plan. Considering
the actual heavier airplane gross weight, the amount of fuel that would have
been required for the flight to JFK, using the airline's standard cruise
performance profile, would have increased. Also, the flight plan factored in
only 28 minutes of reserve fuel, equating to 10 percent of the planned en
route flight time from Medellin to JFK.
U.S. airlines, as well as most international airlines, require the

flightcrew and the dispatch function to keep each other informed of
conditions and events that may alter the planned conduct of the flight. One
of the primary reasons for this requirement is to provide for redundancy in
the operational control of the flight.
54
The dispatch function plays a critical role in the operations

planning and conduct of a flight. This is especially true for situations
involving deteriorating weather and air traffic delays. During such times,
the dispatcher and flightcrew work together to determine the most prudent
course of action in ensuring the safety of the flight. The dispatcher who
"actively" follows a flight is often better able to bring to these corporate
discussions a broader picture of environmental and operational-related
factors that the flightcrew might not be fully aware of, or have anticipated.
Recorded air/ground communications between dispatch and numerous

air carrier flights (Pan American World Airways, Inc. - Pan Am - Flight
Control) that were waiting clearance to land at JFK on the evening of the
accident revealed that as the flights arrived in the New York area, they
contacted their respective dispatch facilities forwarding information on
their fuel status and intentions. The dispatchers, in turn, kept their
flights up to date on the dynamic weather and ATC situation at JFK, the
availability of alternate landing sites, and the fuel quantity necessary to
proceed safely to them. The respective flightcrews and dispatchers confirmed
the specific time when the flight would begin its diversion to the agreed
upon alternate landing site.
Avianca's General Operations Policy Manual required the captain and

the dispatcher to establish communication with each other for "messages
related to operational development or occurrences that are different than the
original flight plan, such as weather conditions at the terminal or en route,
availability of facility or services at the terminal or en route, a
significant change of the flight plan, a deviation, or an emergency
notification." Communication could have been established through the use of
the high frequency (HF) radio on board the airplane or through the Dispatch
Services dispatcher in Miami with which Avianca Airlines had a contract.
The Safety Board was unable to determine why the flightcrew and the
dispatcher did not communicate with each other when they were clearly able to
do so.
The Safety Board believes that Avianca Airlines, the DAAC, and the
international aviation community, in general, should review their respective
policies, procedures, and training to ensure that adequate emphasis is being
placed on the dual responsibility that flight dispatchers and flightcrews
have in keeping each other informed of events and situations that differ from
those mutually agreed upon in the dispatch release.
While the intracockpit conversations of the flightcrew were only

recorded for the last 40 minutes of the flight, there is no record of
contacts between AVA052 and FAA flight service stations or flight' watch
during the flight. The Safety Board was unable to determine why the
flightcrew did not use these valuable inflight services during the flight.
This failure is especially serious because of the multiple holds that the
flight encountered before its fuel state became critical.
Despite the findings about the inadequacy of the,flight planning

and dispatch aspects of AVA052, the airplane still had sufficient fuel to
complete its flight safely. However, air traffic delays because of weather
55
and traffic at JFK resulted in AVA052 entering holding on three occasions.

During the first two holding periods, lasting 19 and 29 minutes
respectively, the flightcrew expressed no concerns to ATC and did not make
inquiries about the situation at JFK.
2.3 Communications--Flightcrew(CVR)
The first indication that the flightcrew had some concerns about
weather, and possibly the fuel state, occurred about 2009. At this time,
AVA052 requested information about delays into Boston from the Washington
ARTCC controller, after being in holding about 26 minutes at BOSTON
intersection. The controller informed the flightcrew that Boston was open
and accepting traffic and that the flight could expect as much as 30
additional minutes of holding in the NY ARTCC airspace. There was no further
indication from the flightcrew about AVA052's fuel state until after the
airplane had been in holding at CAMRN for about 28 minutes. At that point,
the flight had been in holding for 1 hour and 6 minutes on three separate
occasions.
One possibility for the flightcrew's delay in expressing its

concerns may have been a misconception of the significance of the EFC's
issued by ATC. The first EFC was for 2030, issued about 8 minutes before the
flight entered holding at CAMRN, and the second EFC was for 2039 as the
flight entered holding at CAMRN. The flightcrew may have assumed that the
previous EFC's were valid times for which they would receive clearance to
depart holding and begin the approach to JFK before the fuel state became
more critical. In fact, EFC's are merely estimates by the controllers based
on a dynamic traffic and weather situation and are issued to provide a time
to commence the approach should the flight lose radio contact. When ATC
issued a third EFC of 2105, the flightcrew apparently finally realized that
they had to commence an approach and therefore requested priority handling.
However, the Safety Board concludes 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, at 2046:24, "It was Boston, but we can't do it now,
we, we, don't, we run out of fuel 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.
Moreover, AVA052's fuel state at the time it was cleared from

holding at CAMRN to commence its 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 make it to 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.
1
56
When the flight engineer entered 17,000 pounds of fuel remaining

upon beginning the descent from FL370, the flightcrew should have estimated
the distance and time remaining to destination, approach, alternate, and the
reserve fuel required, in order to ensure that there was sufficient fuel for
the flight. Included in these calculations should be the fuel quantity that
the captain would want on board as he commenced the first approach. This
latter fuel figure, commonly referred to as the "minimum approach/landing
fuel quantity," should be a part of a flightcrew's calculations as the flight
begins descent for landing. There is no indication that the flightcrew of
AVA052 had calculated or established such a figure. Again, if a dispatch
system had been functioning for AVA052, the dispatcher could have assisted in
these calculations and contingencies could have been established jointly by
the dispatcher and flightcrew.
The airline's only written procedure for minimum fuel operation was
published in its B-707 Operations Manual. The procedure was based upon an
indicated fuel quantity in any main tank of 1,000 pounds or less. The
procedure did not address a minimum fuel quantity for which a flight should
be at the outer marker, inbound to the runway.
The Boeing Company, on February 15, 1980, as a result of some low-

fuel operations and incidents, issued Operations Manual Bulletin 80-l to all
B-707 operators. The bulletin provided information regarding flight
operations with low fuel indications. Boeing recommended that 7,000 pounds
be used as the minimum indicated amount of fuel for landing. Boeing assumed
the worst case main tank fuel quantity indicating error of 2,700 pounds, and
a minimum of 1,000 pounds in each of the airplane's four main fuel tanks.
The B-707 Airplane Operations Manual states that a minimum fuel

condition exists when the indicated amount of fuel in any main tank is
1,000 pounds or less. The procedure calls for the flightcrew to observe
proper fuselage attitude and acceleration to prevent momentary fuel
starvation. The manufacturer further recommends that if a delay is
anticipated due to radar vectoring, or if there is a possibility of a go-
around, additional fuel should be added to the minimum amount necessary for a
safe landing.
Because the CVR retained only 40 minutes of intracockpit

conversations, the Safety Board could not determine whether the crew
discussed, prior to their departure from CAMRN, the minimum fuel level that
they should have onboard when commencing the approach. However, it is
apparent from air-to-ground transmissions while holding at CAMRN (first, the
expressed need for "priority" at about 2045 and second, the observations that
they could hold only 5 minutes and that they could not reach Boston only
minutes later) that the crew were 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 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 condition. At that time, they could have declared an emergency,
57
or at least requested direct routing to the final approach in order to arrive

with an acceptable approach minimum fuel level.
Shortly thereafter, however, intracockpit conversations beginning

about 2109:21 suggest that the flightcrew assumed that the flight was
receiving priority handling.
The second officer had just completed briefing the procedure for
less than 1,000 pounds in any tank when, at 2109:29, he said, "they already
know we are in bad condition." The captain said, "no, they are descending
us," and the first officer said, "one thousand feet." The captain replied,
"ah yes," as if to acknowledge that the controller was giving the flight
priority. The second officer responded immediately, "they are giving us
priority." This conversation suggests that the flightcrew believed that ATC
was aware of their critical situation and that ATC was providing "priority"
service. However, the events and time involved in the vectoring for the
approach should have indicated much earlier to the flightcrew that they were
only receiving routine service, and they should have made inquiries to verify
the situation.
The intracockpit conversations during the ILS approach concerned

configuring the airplane for landing and announcing various flight
conditions, including the onset of windshear when the airplane went below the
glideslope.
After the flight discontinued its approach to JFK (initiated about

2123:28, when the captain called for the landing gear to be raised), the
captain advised the first officer, "tell them we are in 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
controller was not alerted to the severity of the problem. When the tower
controller advised AVA052 to contact the NY TRACON again for vectors for the
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.
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 of AVA052 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...."
1
58
These intracockpit 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 communications. The captain may have been
preoccupied with flying the airplane and paying little attention to the first
officer's ATC radio transmissions. However, the Safety Board believes it
more likely that his limited command of the English language prevented him
from effectively monitoring the content of the transmission. The Safety
Board further believes 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 CAMRN.
In summary, the Safety Board believes that the two key factors
leading to this accident were the flightcrew's failure to notify ATC of their
fuel situation while holding at CAMRN in order to ensure arrival at the
approach fix with an adequate approach minimum fuel level and a breakdown in
communications between the flightcrew and ATC, and among the flight
crewmembers.
As a result of a fatal air carrier accident and an incident in

which fuel exhaustion was determined to be causal, the Safety Board issued
Safety Recommendation A-81-14 to the FAA on February 24, 1981. It urged the
FAA to "amend 14 CFR 121 and 14 CFR 135 to require that all air carrier
operators include in their flight operations manuals the minimum operational
fuel requirements of their aircraft, including fuel quantities below which a
landing should not be delayed . . ..In determining minimum fuel quantities,
allowances should be made for fuel quantity measuring system tolerances and
for the possibility of a missed approach." The FAA did not act on this
recommendation and the Safety Board classified it "Closed--Unacceptable
Action."
The Safety Board believes that the circumstances of this accident,

as well as other incidents involving low fuel state landings, dictate the
need for a review of regulations and airplane flight manual procedures. They
should include minimum fuel values for various phases of airline flights in
which a landing should not be delayed and in which emergency handling by ATC
should be requested. This review and resultant amendments to regulations and
procedures should include the establishment of criteria for when pilots must
notify ATC that the airplane has reached such a fuel state that it should be
en route to its destination or alternate airport without the delay that can
occur with routine handling and therefore when emergency handling is
required.
Much of the flightcrew's failure to communicate effectively

resulted from limitations in their ability to use the English language, and
in their knowledge of standard ATC terminology. But the flightcrew also did
not communicate effectively among themselves in their native language in
59
addressing the operational problems they encountered. Specifically, the

captain did not make use of dispatch and other resources available to him and
he did not demonstrate the leadership decisionmaking and management skills
needed under the circumstances. Further, the first officer and flight
engineer did not provide the kind of active team support to the captain that
was needed under the circumstances.
Air carrier accident investigation experience over the past

20 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 cockpit crewmembers. This experience has led to much
greater emphasis on a team approach to training airline flightcrews by many
airlines.
This approach, generally known as Cockpit Resource Management

(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 flightcrews, and to
foster the use of all the resources at their disposal. FAA Advisory Circular
120-51 issued on December 1, 1989, provides guidance for the development of
CRM training.
A training technique related to CRM, which emerged as a logical and

parallel development based on accident experience, is Line Oriented Flight
Training (LOFT). LOFT is intended to facilitate the transition from flight
simulator training to line flying. LOFT training involves the use of a
complete crew in a realistic, real-time, no jeopardy training environment
(a simulation) where the results of crewmembers' actions are allowed to occur
without instructor intervention. LOFT is a well-proven method of providing
practice and feedback in crew coordination and problem solving which also has
c$n;dAwidespread acceptance in the airline community and strong support by
The Safety Board believes that the AVA052 flightcrew's ability to
perform' their duties on the accident flight could have been improved
significantly if they had received CRM and LOFT training as part of their
initial and recurrent qualification for line operations. Therefore, the
Safety Board believes that Avianca Airlines should incorporate CRM and LOFT
training concepts into the training all of its flightcrews.
2.4 Flight Data Recorder (FDR)
The analysis of the final approach was made more difficult because
the FDR was inoperative. The flight data recorder that was on this aircraft
was an oscillographic foil flight data recorder. The FAA required that these
recorders be replaced by digital flight data recorders on U.S.-registered
aircraft as of May 26, 1989, because of a history of mechanical malfunctions
and because of their limited recording capacity.
In May 1990, the Safety Board issued two safety recommendations to

the FAA because of the Board's concerns about foreign air carriers operating
with foil flight data recorders in the United States. Safety Recommendation
A-90-73 recommended that the FAA audit U.S.-licensed repair stations to
60
ensure that the work they perform for the foreign operators is in accordance
with established maintenance procedures. The FAA responded that the repair
standards for foreign carriers are established by the state of registry and
that the FAA has no authority to oversee work conducted for a foreign
operator. The Safety Board classified this recommendation as
"Closed Reconsidered."
Member states of ICAO have developed international standards for

flight data recorders. These standards require that international operators
install a flight recorder on the type of aircraft involved in this accident,
but the standards only recommend (not require) that the flight data recorder
be a digital flight data recorder. Safety Recommendation A-90-75 asked the
FAA to require that foreign air carriers operating in the United States
upgrade their flight recorders with digital models to adhere to the same
flight recorder standards as U.S. air carriers. The FAA responded that it
has no authority to require that foreign air carriers meet more than the
minimum flight recorder standards as set forth by international agreement
through ICAO. The Safety Board has classified this recommendation as
"Open Unacceptable Response" and urges the FAA to take a more active role in
ensuring upgraded international standards.
2.5 Coimnunications--Controllers
Communications between ATC and AVA052 were routine until the

flight requested information about delays into Boston while it was holding at
BOSTON intersection. The reason for this inquiry was not determined;
however, it is possible that the flightcrew had reviewed the weather
information received from dispatch or had become aware of delays and poor
weather by another source and were concerned. By this time, the flight had
already held twice, for about 45 minutes, and had probably reached a fuel
state that prompted the inquiry. The controller's actions regarding
informing the flightcrew about delays and holding in the next ARTCC airspace
were proper and in accordance with ATC directives and practices. That
information should have prompted more concern on the part of the pilots;
however, there is no evidence of such concern, and the flight progressed
toward its destination.
After each holding of AVA052, the flight was provided with a

clearance beyond the holding fix, which included a clearance limit for JFK
and an EFC time. However, after holding at ORF and BOSTON, the flight was
held at CAMRN. All clearances issued were in compliance with ATC directives;
however, it is possible that the flightcrew was misled by the clearances.
That is, they may have interpreted the EFC's as actual times that they would
be cleared to continue to the destination without further delay and they
elected to use the reserve fuel necessary to reach the alternate airport.
The Safety Board was unable to determine if the flightcrew made this error of
judgment or if there was some other reason the flightcrew continued to hold
past the time that they should have requested clearance to the alternate
airport.
61
However, at 2044:09, when the NY ARTCC controller handling AVA052

in holding at CAMRN informed the flight about the indefinite delays and
revised the EFC to 2105, the flightcrew advised, "...I think we need
priority, we're passing [garbled]...." The NY radar controller then inquired
about how long the flight could hold and the identity of the flight's
alternate airport.
The NY ARTCC radar controller acted properly by requesting this

information, and the handoff controller, who was assisting the radar
controller, was monitoring these calls. He heard the transmissions from
AVA052 about needing priority and being able to hold for only about
5 minutes; however, he stated that he did not hear the reply to the radar
controller's transmission, " . ..say again your alternate airport." The reply
by AVA052 was, "It was Boston, but we can't do it now, we don't, we run out
of fuel now."
Consequently, when the handoff controller contacted the NY TRACON

about accepting the flight for JFK (or he would set him up for his
alternate), he advised that AVA052 could only hold 5 more minutes. The
handoff controller had not heard the last part of the flightcrew's
transmission and did not mention the flight's request for "priority," or that
the flight had radioed that it could not make Boston now and "...we run out
of fuel now." When the NY TRACON controller accepted AVA052 for an approach
to JFK, he was not aware of any fuel problems or requests for s ecial
handling. Therefore, he .provided routine vectors, including the 360 8 turn
for spacing.
The Safety Board believes that, at the time AVA052 left the
holding pattern at CAMRN, the pilots assumed that they had communicated their
critical fuel situation and the controllers assumed that they had
accommodated AVA052's request for priority.
None of the controllers involved in the handling of AVA052

considered the request for "priority," or the comments about running out of
fuel, to be significant or an emergency request by AVA052. The NY ARTCC
radar and handoff controllers believed that the transmission from AVA052
about only being able to hold for 5 more minutes meant that the flight could
only hold 5 minutes and would then have to divert to its alternate. Both
controllers believed that the intent of the request for priority was to
depart the holding pattern within 5 minutes, either for JFK or Boston, the
alternate.
The Safety Board believes that the assumptions by the NY ARTCC

controllers involved in handling AVA052 in holding at CAMRN were reasonable.
The phrase, "... we run out of fuel now," could be interpreted as an emergency
situation, and thereby could have prompted immediate actions and/or
additional inquiries from the controllers. However, when considered in
context, it is reasonable for the controllers to have assumed that the flight
had only 5 more minutes of fuel before it needed to go to its alternate and
to have assumed that when the flight was cleared from holding and cleared to
JFK in the following minutes that the flight's request for "priority" had
been handled.
62
Similarly, the first officer had advised the NY ARTCC radar

controller that AVA052 could not make its alternate. However, the radar
controller did not verify that the handoff controller had advised the NY
TRACON controller of this information. Both of the NY ARTCC controllers
believed that they had satisfied the flight's request by facilitating
clearance to the destination and had no reason to advise the next facility
that the flight had a fuel problem. This action did not violate any ATC
requirements or procedures.
If the NY TRACON or JFK tower controllers had inquired further

about the flight's fuel state after hearing the comments by the first officer
about "running out of fuel," the situation might have been clarified.
However, as with the previous communications, the controllers had no reason
to believe that the flight was within minutes of actually running out of
fuel. The transmission at 2126:36 from the TRACON controller, who was
providing vectors for the second ILS approach, was a critical one. He said,
II
. ..I'm going to bring you about 15 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." This transmission again failed
to convey to ATC the critical fuel state of the flight.
At 2129:19, the first officer finally asked, "When can you give us
a final...?" and the controller provided a vector. However, shortly
thereafter, the controller advised the flight to climb to 3,000 feet, and the
first officer said, "Ah, negative sir, we just running out of fuel, we okay
three thousand, now we could." Even at this point, the first officer did not
convey the situation clearly to ATC. The engines began to flame out less
than 3 minutes later.
ATC controllers are required to clarify any confusing transmissions

made by pilots that might affect the safe operation of aircraft under their
control. In this case, several controllers had indications of nonroutine
matters, none of which indicated an emergency situation, although such a
situation did exist. Further, the pilots were certainly aware of the
critical situation and apparently believed that they had communicated their
desires. However, the true state of the situation was not clearly
communicated and the airplane ran out of fuel.
In summary, the Safety Board concludes that the communications

from ATC personnel and the handling of AVA052 were proper, considering the
information that the controllers had received from the flight. Nevertheless,
the Safety Board is concerned that the controllers and ATC managers
interviewed after the accident did not place significance on the word
"priority," as stated by AVA052, because controllers are in fact required to
provide priority handling.
ATC controllers share the responsibility for safe flight

operations, although the primary responsibility is for separation of aircraft
in the ATC system. If the NY ARTCC controllers had inquired of the AVA052
flightcrew about the nature of the problem that prompted -the request for
priority, or if the priority request had been passed on to the NY TRACON
63
controller, the confusion that apparently existed within the cockpit might
have been alleviated.
2.6 Pilot and ATC Communications--General
In public hearing testimony, one foreign airline captain referred

to non-U.S. airline pilots with "200-word vocabularies" flying into the
United States. He may have been exaggerating for emphasis, but his point is
well taken. If a pilot, or flightcrew, has a limited English language
vocabulary, he has to rely heavily on the meaning of the words he does know.
If those words have a vague meaning, such as the word "priority," or if a
clear set of terms and words are not used by pilots and controllers,
confusion can occur as it did in this accident.
The word "priority" was used in procedures' manuals provided by the

Boeing Company to the airlines. A captain from Avianca Airlines testified
that the use by the first officer of the word "priority," rather than
"emergency," may have resulted from training at Boeing. The captain also
testified that airline personnel, who provided flight and ground instruction
to the first officer of AVA052, were trained by Boeing. He stated that these
personnel received the impression from the training that the words priority
and emergency conveyed the same meaning to air traffic control. Boeing
Bulletins 80-l and 80-l (Revised), addressing operations with low fuel
quantity indications, state that, "during any operation with very low fuel
quantity, priority handling from ATC should be requested."
Also, in its published procedures, Avianca Airlines uses the term

"priority" regarding the communication of low fuel status. However, when ATC
controllers were asked the phraseology that they would respond to
immediately when a flightcrew indicated a low fuel emergency, they replied
"MAYDAY," "PAN, PAN, PAN," and "Emergency." The controllers stated that,
although they would do their utmost to assist a flight that requested
"priority," the word would not require a specific response and that if a
pilot is in a low fuel emergency and needs emergency handling, he should use
the word "emergency." However, the fact that the NY ARTCC controllers
reacted to facilitate the departure of AVA052 from holding at CAMRN, after
the request for priority, suggests that some level of urgency or nonroutine
status was perceived by the controllers.
The question was also raised during the investigation about

whether pilots might use such words as "priority," when they really needed
emergency assistance because of concern about receiving a flight violation or
having to write a report to the FAA after landing. The FAA officials stated
that there may be questions asked of a pilot who declared such an emergency,
and a written report of the circumstances is required. However, they also
said that there would not be unwarranted actions against any pilot who had
declared an emergency and that if a pilot has an emergency, he or she is
encouraged to declare it.
Despite controllers statements that the word "priority" does not

require them to provide emergency responses, the word does have a definition
in the ATC system. "Priority" is defined in the ATC Handbook as
64
"precedence, established by order of urgency or importance." In this

accident, the NY ARTCC radar controller stated that he felt he had complied
with the flightcrew's request for "priority," since the crew said they could
do only 5 more minutes in holding. Following a land-line call between the
handoff controller and NY TRACON, the flight was cleared out of holding, "to
the Kennedy Airport," in less than a minute.
Although the flightcrew did not declare an emergency at this

point, they did report not having enough fuel to reach their alternate.
Further, the next words the flightcrew heard from the controller were,
II . ..just stand by," then ' . ..cleared to the Kennedy Airport...," the
perception of the flightcrew would most likely be that the controllers
understood their fuel condition. However, the flight received only routine
handling from the controllers for the next 30 minutes. At some point, the
flightcrew should have raised the issue again. Even on a busy frequency, an
inquiry of the subsequent controller, such as, "Did you receive our low fuel
call to NY Center, we said that we no longer have enough fuel to make it to
our alternate?" or "we are declaring an emergency," would have been more than
appropriate for ensuring immediate sequencing to the ILS approach.
Foreign, as well as U.S. pilots can, and often do, routinely ask
for clarification of instructions, even when the radio frequencies are busy,
as on the night of the accident. It is therefore necessary that the few
terms used by pilots and controllers to convey emergency or other critical
information be precise and understandable. The Safety Board believes that
the FAA should work with the International Civil Aviation Organization (ICAO)
to develop a standardized glossary of terms and words with clear definitions
to be disseminated to the international airline industry. For example, if
'emergency low fuel" were defined to mean that 20 minutes remain until tanks
are dry, and pilots and controllers understand that language, there should be
less tendency to try to convey the situation with less precise information,
such as "we need priority, please," when a true emergency exists.
As a result of the evidence collected by the Safety Board early in

the investigation, on February 21, 1990, it issued a letter to the FAA
Administrator recommending:
Immediately notify all domestic and foreign air carriers to

emphasize that all pilots operating commercial air transport
flights in the United States (U.S.) National Airspace System
(NAS) must be thoroughly knowledgeable of the flight operating
and air traffic control (ATC) rules and procedures, including
standard phraseology, for operating in the U.S. NAS. (Class I,
Urgent Action) (A-90-9)
This information is included in several publications: Part I of

Annex 6 to the Convention on International Civil Aviation, the U.S. Federal
Aviation Regulations, the Air Carrier's Operational Specifications issued by
the Administrator of the FAA, the U.S. Aeronautical Information Publication,
the U.S. Airman's Information Manual, Notices to Airmen, Advisory Circulares,
and the U.S. Air Traffic Control Handbook (7110.65F). Pilots must be
particularly familiar with their duties and responsibilities affecting flight
65
operations and safety which include: fuel supply, emergency conditions,

requests for assistance, declaring a state of minimum fuel, and declaring an
emergency for additional ATC assistance to ensure a safe landing.
Immediately disseminate the contents of this safety

recommendation letter (A-90-9 through -11) to all air carrier
operators involved in commercial air transport operations in
the United States National Airspace System. (Class I, Urgent
Action) (A-90-10)
Immediately issue a General Notice (GENOT) directing

management of all air traffic control (ATC) facilities to
formally brief all air traffic controllers on the
circumstances of the January 25, 1990, accident of Avianca
Airlines flight 052 and to emphasize the need to request from
flightcrews clarification of unclear or ambiguous
transmissions that convey a possible emergency situation or
the need for additional ATC assistance. (Class I, Urgent
Action) (A-90-11)
On April 12, 1990, the FAA Administrator responded to safety

recommendations A-90-9 through -11. Regarding recommendations
A-90-9 and -10, the FAA issued Action Notice 8430.33, notifying all principal
operations inspectors to advise all domestic and foreign carriers to emphasis
the need for pilots to be thoroughly knowledgeable of the flight operating
procedures and pertinent air traffic rules and procedures. The Action Notice
transmitted a copy of the Safety Board's safety recommendation letter to the
inspectors. The FAA also incorporated the contents of the action notice in
FAA Order 8430.17, Air Carrier Operations Bulletins. As a result of these
actions, and based on a review of the actions taken by the FAA, on June 22,
1990, the Safety Board classified A-90-9 and -10 "Closed--Acceptable Action."
Regarding A-90-11, the FAA issued a GENOT requiring all ATC

facility managers to ensure that all ATC facility personnel were briefed on
the contents of the Safety Board's safety recommendations resulting from the
AVA052 accident. The GENOT also emphasized the need for complete and
thorough communications between controllers and pilots. Based on those
actions, on June 22, 1990, the Safety Board classified A-90-11,
"Closed Acceptable Action."
In spite of these corrective actions, the Safety Board believes

that there is a need for the FAA to review all official definitions of words
and phrases used to describe minimum and emergency fuel. The Safety Board
believes that the FAA should also coordinate any review of this subject with
ICAO to ensure that the FAA's ATC phraseology is consistent with the
Standards and Recommended Practices of ICAO. The evidence gathered by the
Safety Board during its investigation of the Avianca accident suggests that
the FAA ATC phraseology is not always understood by foreign pilots.
The Safety Board believes that a number of terms that are clearly
understood by both pilots and controllers should be developed and
disseminated worldwide to help prevent another accident similar to AVA052.
66
The Safety Board's examination of other "minimum fuel" incidents involving

both U.S. and foreign airlines suggests that language confusion and imprecise
understanding of critical words exist that could lead to another accident.
2.7 Flightcrew Performance--The ILS Approach
If the flightcrew of AVA052 had been able to complete the first ILS
approach and land successfully, the accident would not have occurred.
Moreover, the critical fuel state of the airplane at the time of landing
would only have been known by the flightcrew and perhaps later by the
Avianca flight dispatcher. The Safety Board examined the performance of the
flightcrew and the possible factors that affected their ability to complete
the approach.
The observations of other pilots, the prevailing meteorological

conditions, and the examination of ATC radar data confirm that significant
and variable winds were encountered by AVA052 during the ILS approach. The
airplane was flying into a headwind that was generally aligned with the
runway and approach course; however, the wind speed was 60 knots or more at
1,000 feet, about 50 knots at 500 feet and about 20 knots at the surface.
Under such conditions, as the airplane descends, it experiences a decreasing
headwind shear that must be recognized and compensated for by the pilot.
The abnormally high headwind at final approach fix altitude results

in a lower groundspeed than the pilot normally encounters when intercepting
the glideslope. In addition, the airplane's rate of descent to maintain the
3O inertial flightpath will be substantially less than normal. To establish
the airplane on the glideslope, the pilot must use greater-than-normal thrust
and a higher-than-normal pitch attitude. Once established on the glideslope,
continual adjustments in thrust and pitch attitude will be necessary to
compensate for the decreasing headwinds as the airplane descends. Ideally,
the thrust and pitch attitude at any instant should be that required to
accelerate the airplane at a rate equal to the rate of change of the
longitudinal wind component while also changing the rate of descent to stay
on the glideslope as groundspeed increases. While a successful approach was
within the airplane's capability under the existing conditions, as evidenced
by the performance of other flightcrews, the approach did present some
challenges to the crew of AVA052.
It appears that the pilot of AVA052 failed to recognize the high

headwind condition when the airplane approached the glideslope from below.
In addition, the captain called for 40° of flaps at 2119:21, as referenced on
page 9 of this report; at 2120:17, he called for 50° of flaps, also
referenced on page 9. The operations manual prohibits the use of 40° or 50°
of flaps with the engine "hush kits" installed. Although the increasingly
critical fuel situation is much more important here than noise abatement
considerations, compliance with the 40° to 50° flap prohibition would have
provided the flight with the benefit of decreasing drag and would therefore
have helped to conserve fuel. During interception of the glideslope, the
captain adjusted thrust and pitch attitude to establish a rate of descent
that would have been normal for a light or no headwind condition. As a
result, the airplane immediately descended below the glideslope as indicated
67
by the radar data and flightcrew comments. It is also apparent that the
captain permitted a significant deviation, (nearly a full glideslope
deviation indicator deflection) to occur before he initiated a positive
response to regain the glideslope. Subsequently, the data show that the
pilot was "chasing" the glideslope with progressively greater-than-required
changes in pitch attitude and/or thrust; as a result, a stabilized descent
was never established.
As AVA052 descended to about 600 feet, about 2 nmi from the

runway, it again descended below the glideslope and had a full below
glideslope deviation indication. The captain again responded with a rapid
climb above the glideslope, at which point he permitted another rapid descent
to develop from which he had difficulty recovering. As a result, the
airplane was well below the glideslope when the captain initiated the missed
approach.
It is also notable that a windshear created by a vertical wind

gradient (winds that change as a function of altitude) affects the airplane
more severely as the rate of change in altitude is increased. Thus, when the
significant rate of descent was permitted to develop, the airplane
encountered a greater windshear and recovery became more difficult.
While the windshear conditions are a factor in the poorly flown ILS
approach, the reported windshear by itself did not fully explain the poorly
flown approach. Other factors, both psychological and physiological help to
explain not only the crew's performance on the approach, but their lack of
anticipation of the windshear or any discussion of their need to land on the
first approach as a result of fuel state.
Aircraft maintenance records indicate recurrent problems with the

autopilot, including the altitude hold function. Additionally, the captain
who flew the aircraft just prior to the accident had problems with the flight
director in the approach mode. These factors, as well as the approach
itself, lead the Safety Board to believe that the aircraft might have been
flown manually from Medellin to JFK and that the ILS approach was flown using
the raw data (deviation from glideslope) without the aid of a flight
director.
The hours of manual flying combined with the ever increasing

criticality of the crew's situation are consistent with increasing fatigue
and adverse stress reactions. This situation is most evident in the
captain's decreasing ability to timeshare multiple tasks. The captain, with
limited English language skills, was dependent on the nonflying copilot to
communicate with ATC. During the initial radar vectoring from CAMRN
intersection, the captain followed the copilot's ATC instructions and on
occasion responded to ATC instructions without translation to Spanish.
However, from the time that the airplane was on the final vector to the
localizer until the missed approach, there were nine distinct incidents of
the captain asking for instructions to be repeated or for confirmation of
the airplane's configuration. Additionally, the captain asked the copilot to
speak louder. These events are all signs of fatigue and adverse stress.
68
Laboratory experiments using flight simulators in which the pilot

executes an ILS approach with simultaneous communication tasks exhibit the
same type of results. Performance on communication tasks degrades
significantly with increasing flight difficulty, and performance on
glideslope tracking decreases at high levels of stress.
These stress conditions are evident not only in the flightcrew's

performance on the ILS approach but in their failure to consider that they
could not allow a missed approach. Moreover, when they did have a missed
approach, they did not take control of their situation and request the
shortest path back to the airport.
The Safety Board thus concludes that the flightcrew's performance--

their inability to maintain a position on the glideslope--was attributable to
a combination of the windshear condition, fatigue resulting from a long
flight, possibly flown without the benefit of an operable autopilot, and
stress aggravated by their concern about the remaining fuel.
2.8 Central Flow Control Facility (CFCF)--Traffic Management
The ground delay program for the JFK airport was negotiated and
implemented based upon the assumption that runway 13L would be the arrival
runway during the afternoon and evening shift on January 25, 1990. The
weather forecast for the time period that the program was needed, 19002
until 03002, indicated that there would be strong southeast winds at the
surface requiring the use of runway 13 left as the only arrival runway.
Early in the morning, the day shift supervisor at the CFCF had
several discussions with the NY TRACON specialist (N90) at the Traffic
Management Unit (TMU). During the discussions in which the airport
acceptance rate (AAR) was being negotiated, the N90 TMU specialist believed
the AAR should be set at approximately 28 arrivals per hour. The CFCF
supervisor asked the specialist if it would be possible to land 30 to 32
airplanes per hour. The N90 specialist then referenced the engineered
performance standards (EPS) and advised the CFCF supervisor that the EPS
reflected and arrival rate of 26 airplanes per hour for runway 13 left under
the forecast weather conditions.
After the program had been developed, the CFCF supervisor called
the N90 specialist to inform him that the program rate had been set at 33
arrivals per hour. The N90 specialist who took the call was not the same
individual who had the earlier discussion with the supervisor. The
supervisor explained to the specialist that the program had been "built" at
an arrival rate of 33 arrival airplanes per hour and stated, "figuring in the
disruption with the rest of the system and one or two guys quitting, I feel
that's a fair ground delay . ..but I want your blessings also." The supervisor
explained that building the program at a lower rate would cause excessively
high ground delays and that if the ground delays went as high as three hours,
they would not be acceptable. The N90 specialist stated, "well why don't you
go with it." The supervisor informed Safety Board investigators that even
though the program was set at a 33 computer rate, the objective was to
achieve a 28 airport acceptance rate as the N90 specialist had asked for.
69
The specialist who actually "built" the program informed Safety Board
investigators that his understanding was that the computer rate and the
airport acceptance rate were to be the same, 33 arrivals per hour, and this
is the number he entered onto the program worksheet. He briefed his relief,
the afternoon specialist, that the airport acceptance rate was to be 33. He
was also under the impression that the program had been computed based upon
the use of runways 22 left and 22 right at the JFK airport, and he was never
aware that the program was based upon the use of runway 13 left. The JFK
ground delay program was transmitted successfully to all domestic ARTCC's at
approximately 15252.
Copies of the engineered performance standards for the JFK airport

were provided to Safety Board investigators. According to the EPS for
runway 13 left, the highest number of arrivals that can be accomodated on
that runway during instrument meteorological conditions (IFR) is 24
airplanes. The highest number of arrivals that can be accommodated on
runway 22 left during IFR conditions is 23 airplanes. The specialists and
supervisors from CFCF informed Safety Board investigators that the EPS
figures are not necessarily the figures that the CFCF would use when
determining the need for or the computing of a ground delay program. They
stated that it is the terminal facility that actually determines the airport
acceptance rate and that rate is normally higher than the designated EPS
number. The Assistant Manager for Traffic Management at the CFCF informed
Safety Board investigators that the 33 rate for runway 13 left was a little
high in itself but was based upon the assumption that the high number of
programs in place and the number of cancelled flights that were expected on
January 25 would make the 33 rate acceptable. He also stated that a 33 rate
for runway 22 left was an excellent rate.
Although the cause of this accident clearly involved the inadequate

actions of the flightcrew of AVA052, the weather and air traffic conditions
at JFK during the hours before the accident set the stage for the delays that
led to the holding of the flight for more than 1 hour en route. The normal
high density of traffic in the New York area was made worse by the
prevailing weather during the day. The FAA CFCF had a program in place
beginning at 1400 to attempt to prevent problems, including excessive
airborne holding. However, this program failed for several reasons.
The investigation revealed that the traffic management program in

effect for JFK did allow for the arrival of sufficient numbers of airplanes
to accomplish an airport acceptance rate of 33 arrivals per hour (except
during the first hour of the program when only 17 airplanes landed) at which
the program was set. However, the program was compromised when the weather
deteriorated to less than that needed for aircraft to land on runway 22
right, and missed approaches began on runway 22 left.
Although the program was still allowing 33 airplanes per hour into
the system for JFK, CFCF personnel did not react appropriately or timely
enough to prevent the large numbers of airplanes that ended up in holding
patterns waiting for the weather conditions to improve. When CFCF did react
by implementing a ground stop for traffic destined for JFK, the action was
not sufficient to abate the airborne holding which had already begun.
1
70
Many of the flights inbound to the JFK airport had departed from
overseas or other long distance airports. When it first became necessary to
implement the ground stop for JFK arrivals, most of the long distance traffic
was already airborne and a ground stop, therefore, was not effective for
those flights. However, a review of the data from CFCF revealed that at
1600, when runway 22 right was already below minimums and the missed
approaches had already begun on runway 22 left, there were approximately 38
airplanes from the ZDC and ZNY centers that had not departed for JFK.
Nationwide, there were still more than 100 airplanes scheduled to depart for
JFK from domestic airports.
A ground stop implemented at 1600 and remaining in effect for a

sufficient number of hours would have impacted the overall air traffic
system to a considerable degree, but it would not have been effective in
alleviating the large inventory of airborne flights waiting to land at JFK.
The Safety Board, therefore, believes that CFCF did not implement a ground
stop for traffic landing at JFK in time to prevent the excessive airborne
holding that occurred on the evening of the accident. After the ground stop
was implemented, it was not of sufficient duration nor did it include a
sufficient number of centers to be effective in alleviating the airborne
holding that was occurring.
The investigation also revealed that National Weather Service

(NWS) personnel working in the Weather Service Units at CFCF and ZNY did not
inform traffic management personnel of the severe wind conditions that
affected the controller's ability to provide appropriate separation in the
approach control airspace of the Kennedy sector during the evening shift on
January 25. These winds, as well as the deteriorating weather conditions,
were causing the missed approaches.
Traffic management personnel informed the Safety Board that if

they had known about the wind conditions, the program could have been
implemented at a lower airport acceptance rate, thereby reducing the airborne
inventory of airplanes arriving at JFK during each hour of the traffic
management program. If CFCF had known about the wind conditions, they would
have adjusted the number of aircraft. The Safety Board believes that the NWS
personnel failed to communicate this information to the CFCF traffic
management specialists.
The JFK program was implemented based upon forecast weather

conditions that should have permitted the continuous use of the ILS approach
to runway 22 left and the use of runway 22 right for arrivals until 2000.
The visibility was expected to deteriorate to l/2 mile. In fact, the
visibility was l/4 mile as early as 1600. The minimum prevailing visibility
required for the ILS approach to runway 22 right is 3/4 mile, and for runway
22 left, l/2 mile. If approaches had continued on both runways until 2000,
the airborne inventory of airplanes might have been much smaller.
The Safety Board believes that the forecast was .inaccurate and
that the traffic management program was implemented based upon a forecast of
better weather conditions than those that actually existed. The Safety Board
k
71
also believes that if the forecast had been accurate the program would have
been implemented at a lower airport acceptance rate and that the inventory of
airplanes in holding patterns could have been much lower.
The Safety Board believes that the traffic management efforts of

the CFCF personnel were neither accurate nor timely for traffic into and out
of JFK. The Safety Board believes that both of these situations contributed
to the events that led to this accident; however, these events cannot be
linked directly to the cause of the accident. This conclusion is based on
the fact that the flightcrew had several opportunities to prevent the
accident.
2.9 Survivability
According to the lead flight attendant, seated in 2C, who survived

with serious injuries, there was no warning to the cabin from the cockpit
crew 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 pretakeoff briefing, and on evacuation
procedures. However, after the failure of all four engines and generators,
the ability of the cockpit to communicate with the cabin on the PA system
would have terminated. If the cabin crewmembers and passengers had assumed
the brace position before the impact, the severity of some of the injuries
might have been reduced.
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 probably 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 seat units from their floor attachments probably pushed
passengers forward into other passengers, seat units, and other wreckage
debris, causing head injuries and lacerations.
Two of the 10 surviving infants sustained minor injuries,

consisting of multiple contusions and abrasions and eight sustained serious
injuries, consisting of limb fractures and head injuries. The 10 infants were
either held by adult passengers or were belted into the same seat with the
passengers. Surviving passengers who held infants reported that during the
impact the infants were ejected from their grasp and that they were
generally unable to locate them in the darkness after the impact.
The Safety Board believes that the problems experienced in this and
other accidents illustrate the impossibility of parents holding onto infants
during a crash. If the infants had occupied FAA-approved restraint systems,
injuries would most likely not have been as severe.
The Safety Board addressed the subject of infant restraints in

safety recommendations issued on May 30, 1990. They were:
72
Revise 14 CFR 91, 121, and 135 to require that all occupants
be restrained during takeoff, landing, and turbulent
conditions, and that all infants and small children below the
weight of 40 pounds and under the height of 40 inches be
restrained in an approved child restraint system appropriate
to their height and weight. (Class I, Priority
Action) (A-90-78)
Conduct research to determine the adequacy of aircraft

seatbelts to restrain children too large to use child safety
seats and to develop some suitable means of providing adequate
restraint for such children. (Class II, Priority Action)
(A-90-79)
The FAA Administrator responded to the recommendations on August 6,

1990. Regarding A-90-78, the FAA issued a Notice of Proposed Rulemaking
(NPRM) on February 22, 1990, for child restraint system provisions. The
Safety Board found the provisions in the NPRM unacceptable because they did
not require the use of an approved restraint system. Rather, the provisions
would merely prohibit airlines from denying their use. Consequently, the
Safety Board has classified A-90-78 as "Open--Unacceptable Action."
The FAA responded to recommendation A-90-79 that it has no

research planned to examine adequate restraint systems for children who are
too large to use child safety seats. Consequently, the Safety Board has
classified this recommendation as "Open--Unacceptable Action."
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 had 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
cockpit seats to be equipped with combined seatbelts and shoulder harnesses;
however, ICAO standards do not address these restraint systems.
The right side of the cockpit struck a 42-inch-diameter oak tree

that penetrated the space occupied by the first officer and the flight
engineer, causing nonsurvivable injuries.
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-l
jumpseat, the second was in passenger seat 2A, and the third was in passenger
seat 3C.
73
Sixty-four adult passengers and one 4-month old infant died as a

result of blunt force injuries. It is possible that some of the injuries
could have been reduced, permitting some of these passengers to survive, if
they had been instructed to assume the brace position before impact.
Although there was no fire, it should be noted that the cushions on

the passenger seats were refurbished in March 1987, 9 months before the FAA
regulation became effective requiring seat cushions to have fire-blocking
material. ICAO Annex 8 recommends the fire-blocking material.
Cabin floor proximity emergency escape path lights were not

installed. These lights were required by the FAA in 1988 and ICAO Annex 8
recommends installation of such lights. These lights might have been useful
during the rescue operation. The rescuers remarked that the fractured seats
and debris found in the dark cabin made their job more difficult.
The L-l and R-l emergency evacuation slides had no girt bars
installed and the R-l door had no girt bar floor fittings installed. No girt
bars were found in the wreckage. Such hardware is required by the FAA and
recommended by ICAO Annex 8. Although the six inoperable evacuation slides
were not required in this accident, these deficiencies would have been a
major factor in an emergency where the use of evacuation slides would be
necessary.
2.9.1 Emergency Response
Aircraft rescue and fire fighting (ARFF) vehicles from JFK were not
dispatched to the accident site in the town of Cove Neck, Long Island,
because of the numerous local law enforcement and rescue vehicles available
near the accident site. The local response was timely and effective.
During the rescue effort, approximately 91 ambulances, heavy rescue

vehicles, off-road vehicles and fire trucks of varying sizes responded.
Vehicles came from 37 fire and rescue companies. Access to the impact site
created a bottleneck of traffic on a single, narrow blacktopped residential
road. Considerable congestion resulted as agencies tried to enter the road
to assist and as other agencies tried to exit to transport survivors to local
hospitals. The Nassau County Police Department dispatched helicopters, which
evacuated many of the injured. This department was of considerable help
during the investigation. Such help included an analysis of the department's
emergency response to the accident. Overall, the emergency response and
rescue was exceptional under the difficult circumstances of darkness and the
wreckage location.
74
3. CONCLUSIONS
3.1 Findings
1. The accident occurred when the airplane's engines lost power

as a result of fuel exhaustion while the flight was
maneuvering for a second instrument approach to JFK airport.
2. Examination of the airplane revealed no malfunction of the

engines or fuel system components that could have caused a
premature fuel exhaustion.
3. The flightcrew was not provided with, and they did not
request before departure, the most current weather forecast
available for the destination and selected alternate airport.
4. The alternate airport selected for the flight at the time of

departure did not meet the prescribed weather criteria for an
alternate based on weather information provided to the crew at
the time of departure. The weather conditions worsened at
both the destination and alternate while the flight was en
route.
5. The flight plan of AVA052 did not reflect the most current
upper air data or the actual gross weight of the airplane upon
departure from Medellin.
6. The flightcrew had received appropriate flight and ground

training for the flight, and they possessed appropriate
flight and medical certification required by the Government of
Colombia.
7. The flightcrew was experienced in conducting B-707 flights

from Colombia to the United States.
8. There was no flight following or interaction with the Avianca

Airlines dispatcher for AVA052 following takeoff from
Medellin. None was required by the airline's operations
specifications issued by the FAA under 14 CFR 129 to operate
into the United States.
9. There is no record that while en route the flightcrew

requested updated weather information from any source
regarding the destination or alternate airport.
10. The flightcrew did not adequately communicate its

increasingly critical fuel- situation to the controllers who
handled the flight.
11. The first officer, who made all recorded transmissions to

U.S. controllers, was sufficiently proficient in English to be
understood by air traffic control personnel.
75
12. The first officer incorrectly assumed that his request for
priority handling by air traffic control had been understood
as a request for emergency handling. The captain experienced
difficulties in monitoring communications between the flight
and air traffic control.
13. The controllers' actions in response to AVA052's requests

were proper and responsive to a request for priority
handling. They did not understand that an emergency
situation existed.
14. The first officer, who made all recorded radio transmissions
in English, never used the word "Emergency," even when he
radioed that two engines had flamed out, and he did not use
the appropriate phraseology published in United States
aeronautical publications to communicate to air traffic
control the flight's minimum fuel status.
15. The weather conditions at the JFK Airport were worse than
forecast.
16. The captain did not fly the ILS approach in a stabilized
manner, which led to a serious deviation below the glideslope
and to his initiation of a go-around.
17. A windshear on the approach path contributed to the captain's

poor performance on the ILS approach. Although other flights
successfully completed the approach through the same wind
conditions, the captain's performance on the approach was
probably degraded by fatigue after the long flight and by his
reliance on raw glideslope position data rather than on
autopilot or flight director guidance.
18. The Federal Aviation Administration traffic management

programs failed to manage the traffic volume at JFK
effectively, leading to excessive delays and airborne
holdings, including more than 1 hour for AVA052.
19. The Federal Aviation Administration's traffic management

programs for JFK did not adequately account for overseas
arrivals and missed approaches at JFK.
20. Cabin crewmembers and passengers were not warned of the

impending crash landing, which may have contributed to the
severity of the injuries sustained.
21. The serious and fatal injuries were the result of blunt force
trauma because of high vertical and longitudinal deceleration
forces during the impact sequence.
1
76
22. The emergency evacuation slides were inoperative because of

the lack of slide girt bars and associated attachment
hardware.
23. There were no shoulder harnesses or inertia reels installed on

captain's and first officer's seats.
24. The response of fire and rescue personnel was timely and
effective, and the use of helicopters by the Nassau
County Police Department probably saved lives.
3.2 Probable Cause
The National Transportation Safety Board determines that the

probable cause of this accident was the failure of the flightcrew to
adequately manage the airplane's fuel load, and their failure to communicate
an emergency fuel situation to air traffic control before fuel exhaustion
occurred. Contributing to the accident was the flightcrew's failure to use
an airline operational control dispatch system to assist them during the
international flight into a high-density airport in poor weather. Also
contributing to the accident was inadequate traffic flow management by the
FAA and the lack of standardized understandable terminology for pilots and
controllers for minimum and emergency fuel states.
The Safety Board also determines that windshear, crew fatigue and
stress were factors that led to the unsuccessful completion of the first
approach and thus contributed to the accident.
4. RECOMMENDATIONS
As a result of this accident, the National Transportation Safety

Board makes the following recommendations:
--to the Federal Aviation Administration:
Develop in cooperation with the International Civil Aviation

Organization a standardized glossary of definitions, terms,
words, and phrases to be used that are clearly understandable
to both pilots and air traffic controllers regarding minimum
and emergency fuel communications. (Class II, Priority
Action) (A-91-33)
Conduct a comprehensive study of the Central Flow Control

Facility and the Traffic Management System, by the Office of
Safety/Quality Assurance, to determine the effectiveness and
appropriateness of training, responsibilities, procedures,
and methods of application for the Traffic Management System.
(Class II, Priority Action) (A-91-34)
77
Require that transport category airplane flight manuals

include procedures specifying minimum fuel values for various
phases of airline flights at which a landing should not be
delayed and when emergency handling by ATC should be
requested. The manual requirement and associated amendments
to regulations and procedures should include criteria for when
ATC must be notified that the airplane must be en route to its
destination or alternate airport via routine handling, and
when emergency handling is required. (Class II, Priority
Action) (A-91-35)
Incorporate into air route traffic control centers equipment

to provide a recorded broadcast of traffic management
information that can be monitored by all aircraft within each
center's boundaries to provide pilots with early indications
of potential delays enroute. (Class II, Priority Action)
(A-91-36)
--to the Director, Administration Aviation Civil (DAAC), Colombia:
Review policies, procedures, training, and oversight activity

to ensure that adequate emphasis is being placed on the dual
responsibility that flight dispatchers and flightcrews have in
keeping each other informed of events and situations that
differ from those mutually agreed upon in the dispatch
release. (Class II,Priority Action) (A-91-37)
Require that Avianca Airlines incorporate Cockpit Resource

Management and Line Oriented Flight Training concepts into its
flightcrew training program. (Class II, Priority Action)
(A-91-38)
On February 21, 1990, the following Safety Recommendations were

issued to the Federal Aviation Administration:
A-90-9
Immediately notify all domestic and foreign air carriers to

emphasize that all pilots operating commercial air transport
flights in the U.S. National Airspace System must be
thoroughly knowledgeable of the flight operating and air
traffic control rules and procedures, including standard
phraseology, for operating in the U.S. NAS.
A-90- 10
Immediately disseminate the contents of the recommendation to

all air carrier operators involved in commercial air transport
operations in the U.S. NAS.
78
A-90-11
Immediately issue a General Notice directing management of all

air traffic control facilities to formally brief all air
traffic controllers on the circumstances of the accident, and
emphasize the need to request from flightcrews clarification
of unclear or ambiguous transmissions that convey a possible
emergency situation or need for additional ATC assistance.
On June 22, 1990, the Safety Board Classified Safety

Recommendations A-90-9 through -11 as "Closed--Acceptable Action."
BY THE NATIONAL TRANSPORTATION SAFETY BOARD
/s/ James L Kolstad

Chairma;
/s/ Susan Couqhlin

Vice Chairman
/s/ Jozbe:. Lauber
/s/ fvrvr;oDher A. Hart
Jim Burnett, Member, filed the following dissenting statement:
Although I support the probable cause and recommendations as

adopted, I have voted against the adoption of this report because it fails to
adequately deal with the role of the air traffic control (ATC) services in
this accident scenario.
Air traffic control services were inadequate in four respects.
1. The Washington ARTCC R50 controller failed to inform the

flightcrew of AVA052 of additional holding in the
Washington ARTCC area.
2. The JFK tower local controller failed to transmit the RVR

and the latest windshear report to the flightcrew of
AVA052.
3. The JFK tower local controller failed to forward to the

N90 FV controller the remark by the flightcrew concerning
their fuel situation.
I
79
4. The Controller-in-Charge in the JFK tower failed to

ensure that the ATIS contained the pilot reports of
windshear as required.
While I can accept the argument that such unsatisfactory service

was not causal to this accident, this pattern of substandard service reflects
poorly on the ATC system and raises serious safety concerns.
Although the reasons for this pattern of substandard service have

not been developed in the report, I suspect that it has little to do, in this
case, with the experience level of the controllers and a great deal to do
with controller workload under the weather conditions and with the fact that
the Federal Aviation Administration flow control intentionally allowed a
greater flow of traffic, bound for JFK, into the system than could be safely
and efficiently accommodated by the system.
/s/ Jim Burnett

Member
Christopher Hart, Member, filed the following partial

concurring/dissenting statement:
I concur in part with the probable cause as adopted, but I dissent

in part because I do not agree that a contributing factor is "the lack of
standardized understandable terminology for pilots and controllers for
minimum and emergency fuel states." We do have standardized understandable
terminology -- "Mayday" internationally, and "Emergency" in English -- that
would have adequately communicated the existence of a dangerous situation,
and the problem was that the pilots failed to use this terminology with the
controllers.
The DAAC of the Government of Colombia provided comments on the

report and probable cause in accordance with the provisions of Annex 13 to
the International Convention on Civil Aviation. These comments in both
English and Spanish are attached as appendix F.
April 30, 1991

I 1
81
5. APPENDIXES
APPENDIX A
INVESTIGATION AND HEARING
1. Investigation
The National Transportation Safety Board was notified of the

accident involving Avianca Airlines flight 052 at about 2230, January 25,
1990. The "Go Team" assembled immediately at Federal Aviation Administration
jet transport at National Airport, near Washington, D.C., and launched for
New York's LaGuardia Airport. The team arrived at the site of the accident
at 0900, January 26, 1990. Investigative groups were formed, each headed by
an investigator from the Safety Board. The following groups were formed:
Operations, Air Traffic Control, Weather, Survival Factors, Airplane
Structures, Powerplants, Airplane Systems, Maintenance Records, and Airplane
Performance. In addition, a group was formed at Safety Board Headquarters,
in Washington, D.C., to examine and read out any information on the cockpit
voice recorder and flight data recorder.
The following were made parties to the investigation: Federal

Aviation Administration, Avianca Airlines, International Air Line Pilots
Association, the Boeing Commercial Airplane Company, NATCA, and Pratt &
Whitney. The DAAC of Colombia appointed an Accredited Representative to
participate in the investigation.
82
APPENDIX B
CVR TRANSCRIPT
TRANSCRIPT DF A COLLINS MODEL 642C-I COCKPIT VOICE RECORDER S/N 808 REtjoVE
FROM A AVIANCA INTERNATIONAL AIRLINES BOEING 707.3218, HK2016 UHICHWAS
INVOLVED IN A ACCIDENT ON JANUARY 2p, 1990 AT COVE NECK, NEU YORK.
CAM Cockpit area microphone voice or sound source
RDO Radio transmission from accident aircraft
-1 Voice identified as Captain
-2 Voice identified as First Officer
-3 Voice identified as Second Officer

-? Voice unidentified
l Unintelligible word
e Nonpertinent word
# Expletive deleted
x Break in continuity
0 Questionable text
( 0) Editorial insertion
e Pause
GPKS Ground Proximity Warning System

APP New York Camrn Approach Controller
APPl New York Kennedy Final Vector Controller
TWR New York Kennedy Local Controller (Tower)
(cont.)
83
PAA1812 Pan American flight 1812
PAN1 Pan American flight 11
PAA Pan American flight 474
AAL4O American Airlines flight 40
AAL American Airlines flight 692
AH520 Avtnsa Airlines flight 520
USA117 USAir flight 117

TWA801 Trans World Airlines flight 801
TWA542 Trans World Airlines flight 542
ELAlO2 Evergreen International Airlines flight 102
NOTE: All times are expressed in Eastern Standrrd'limt. From time 2053:09
to 2115:19 only those radio transmissions to or from the accident
aircraft were transcribed. After 2115:19 until the end of the
recording all radio transmissions are included.
IHlRA-COCKPIT EWiLISH IHlllA-COCKPIT SPARISH AIR-WNMD WrmMICATIoWS
TIE I TIlE & TIE I
!z!!E!E -!z!E!!I e!!Im
2053:09
((start of recording))
2054:23
APP Avianca zero five two turn right heading zero nine zere
2054:25
RDO-2 turning right heading zero niner zero Avianca zero five two
2054:32
CAR-2 zero nine zero on the heading CAM-2 cero nueve cero en el rumba
2054:40
APP Avianca zero five two turn right right turn heading two two zero I'm $
gunna have to spin you sir
2054:45
ROO-2 okay heading two t@ zero avianca zero five two
2054:49
CAM-1 two twenty CAM-l doe veinte
2054:50
CAR-2 two twenty CAM-2 dos veinte
2055:07
CAM-l how much CAM-1 cuanto
CAR-2 two twenty CAM-2 dos veinte
2055:08
CAM-l two twenty CAM-1 dos veinte
2055:09
CAM-2 two twenty sir CAR-2 dos veinte si senor
85
IWTRA-URXPIT EELIW IRTRA-COCKJ’IT SPARISH AIR-fiRWIID COMlRICATIoWS
TIE L TIE & TIlE 6
SmRcE
- -UxtERT s!!!!!E!z!!!m s!!!!!z !B!Im
2056:25
RDO-2 thank you very much Avianca zero five two
2056:28
CAM-l what is he saying wind shear CAM-l que dice wind shear
2056:30
CAM-2 he is advising us that a seven CAM-2 que un 727 report0 wind shear en
twenty seven reported a wind approximation--500 pies excediendo la
shear condition during velocidad 10 nudos
approach at five hundred
feet-exceeding the speed
in ten knots
2057:OO
CAM-l it has been all time in this CAM-l es que ha estado todo el tiempo
way, but asi sobado, pero
2058~43
APP Avianca zero five two turn right heading zero six zero
2058:46
RDO-2 turning right heading zero six zero Avianca zero five two heavy
2058:49
CAM-l right
2058:50
CAM-2 right zero six zero CAM-2 right cero seis cero
I~-COCKPIT Ell6LI5H IRTRA-CIXXPIT SPANISH AIR-GROUIO urrrm(ICATIONS
TIM & TM L TIE L
CoNlEnT
SaRcE soIIEcE!BE!L s!!!!!z !z!!!Im
2058:58
CAM-2 estimate CAM-2 estimado
2059:04
CAM-l huh? CAM-l ah
2059:05
CAR-3 what a problem with this CAM-3 Que problem con esta vaiina
2059:57
CAM-l zero seventy CAM-l setenta
2100:04
APP Avianca zero five two stop turn heading zero four zero
2100:07
ROO-2 at zero four zero Avianca zero five two
21OO:lO
CAM-2 ah zero four zero it is better CAM-2 ah cero cuatro cero mas bien
2100:13
CAM-l okay
IRlRA-aJCKPIT EIHJSH IRTRAXEKPIT SPANISH A I R - MrrmwICATItHS
TIlE L TIME I TIIE L
!5outcE G!!!lm z!!!Ez!!!!!!E s!!!EE !x!!m!l
2100:26
((atis information Zulu starts))
-- Kennedy airport information zulu zero one five zero zulu weather indefinite ceiling two hundred sky obscured visibility one quarter light drizzle fog
temperature four eight dew point four seven wind one niner zero at one seven altimeter two niner six niner approach in use ILS runway two two left
departure runway two two right notices to airman stop * control system is out of service replaced by the amber hold bar system center weather advisory
from Allentown to two zero miles south south west of Kenton a solid line of heavy showers and thunderstorms moving north east four zero knots should
reach Philadelphia airport before zero one three zero zulu radar tops to flight level two eight zero New York Center advisory three from zero one four
zero zulu to zero three zero zero zulu to two zero miles north east of Houghnot to one five east of Philadelphia a solid line of thunderstorms one five
miles wide moving north east at four zero knots radar tops to flight level two five zero moderate to severe turbulence and hail reported at one one
thousand between Soberg and Yonkers line shoud move through New York metro between zero two one five zulu and zero three zero zero zulu for additional
information contact New York flight service station use caution for possible radio interference or false transmissions on air traffic control frequencies
in the interest of noise abatement please use the assigned runway advise you have zulu --
2100:39
CAM ((sound of altitude alert chime))
21Ol:lS
APP Avianca zero five two descend and maintain five thousand
2101:17
RDO-2 descend and maintain five thousand Avianca zero five two
2101:31
CAM-2 *
2101:44
APP Avianca zero five two turn right heading heading zero nine zero
2101:46
RDO-2 right heading zero nine zero Avianca zero five two
INTRA-CtlCKPIT ER6LISH IRTRA-COCXPIT SPANISH AIR-@MMIJ -ICATIoI(S
TIllE L TIlE L TIME 6
SaRcE !!!!z!E s!Y!!!zarmrrr s!!!EE -amTENT
21Ol:Sl
CAM-2 zero nine zero on the heading CAM-2 cero nueve cero en el rumbo
2102:24
APP Avianca zero five two turn left heading zero four zero
2102:27
ROO-2 left heading zero four zero Avianca zero five two
2102:29
CAM-l eh Ave Maria pues CAM-l eh Ave Maria pues
2102:31
((stop of atis transmission))
2102:32
CAM-2 but now it is completed, CAM-2 pero ya es completa cierto
isn't
2102:34
CAM-l ((sound of laugh))
CAM-2 complete CAM-2 completa

2102:36
CAM-l one thousand feet CAM-1 mil pies
2102:37
CAM-2 one thousand feet for five CAM-2 mil pies para cinco mil
thousand feet
-
IKlRA-COCKPIT EIIGLISH IRTRA-CllCKPIT SPANISH AIR-6RWIID -ICATIoIIS
TM li TIME I TINE 6
slmmtw
- UMTEWT
- m!!l!zMlcmcT s!!!!!E !z!!m!x
2102:39
APP Avianca zero five two heavy approach one one eight point four
2102:42
RDO-2 one one eight point four so long
2102:44
APP Avianca zero five two and before you go there's a wind shear on final at
fifteen hundred feet it's an increase in ten knots then again at five
hundred feet of ten knots by seven twenty seven New York now on one one
eight point four good night
2102~56
RDO-2 one one eight point four so long
2102: 59 rD
0 I
CAM-l what heading did you say to CAM-l que rumbo me dijo cero cuarenta
me zero forty
2103:OO
CAM-2 yes sir CAM-2 si senor
2103:07
RDO-2 New York Approach Avianca zero five ah two leveling five thousand
2103:ll
APPl Avianca zero five two heavy New York approach good evening fly heading
zero six zero
IRTRA-UMXPIT EKIJSH IRTRAdXllXPIT SPANISH AIR-fiRWllD COIMWICATIOMS
TIlE L TM L TIE L
sn!!E !z!!!m s!!!!EEm!!!m s!!!B!z CaflERT
-
2103:lS
RDO-2 heading zero six zero Avianca zero five two heavy
2103:18
CAM-2 zero six zero on the heading CAM-2 cero seis cero en el rumba
2103:26
CAM-3 what a beautiful CAM-3 que belleza
CAM-3 cleared CAM-3 autorizado
2103333
CAM-l it may be CAM-l puede ser
2103:35
CAM-3 yes CAM-3 si
2103:37
CAM-1 sure CAM-l claro
2103:46
CAM-3 when we have--with thousand CAM-3 es cuando hay uno--con con mil libras
pounds or less in any tank it o menos en cualquier tanque se debe hater un
is necessary to do
2103:53
INlRA-COCKPIT EMtUSH IRTRA-COCRPIT SPANISH AIR-6RfNMD Mrrm(ICATIoWS
TIE I TIE I TIME 6
s!!!!!z B!!Im s!?!!EEarmn 2!AEE !2!!!mE
2103:56
CAM-3 then the go around procedure CAM-3 entonces el go around procedure dice
is stating that the power be aplique la potencia suavemente y evite
applied slowly and to avoid las rapidas alteraciones de1 avion
rapid accelerations and to mantenga el minim, de nose up attitude
have a minimum of nose up
attitude
2104:09
CAM-1 to maintain what CAM-1 mantenga que
2104:lO
CAM-2 minimum minimum nose up CAM-2 minimum minimum nose up attitude o
attitude that means the sea lo menos nariz arriba que uno pueda
less nose up attitude that one
can hold
CAM-3 this thing is going okay CAM-3 esto si que anda bien
2104:27
CAM-3 then flaps to twenty five CAM-3 entonces 10s flaps a veinticinco y
position and maintain Vee mantenga Vee ref mas veinte lo mas
ref plus twenty--the highest alto que de el go around
go around procedure is
starting
INTRA-COCKPIT EKLISH INlRA-CfXKPIT SPANISH AIR-6RWWD COMlMICATIMlS
TIE L TIE L TIE I
s!E!z UMENT s!!!!EMlcmcT s!!!B!x c!!!!mE
2104:34
CAM-3 the flaps sorry retract the CAM-3 retracte 10s flaps perdon retracte
landing gear with positive el tren when positive rate of climb
rate of climb--if any low si cualquier luz de baja presion se
pressure light comes on do prende no ponga el switche en offs
not select the switch in he las bcnnbas de baja he las lutes de
the off position--the low baja precsion de las bombas se prenden
pressure lights of the pumps reduzca la altitud se nariz la actitud
comes on reduce the nose up de nariz arriba
altitude the nose up attitude
2104:57
CAM-3 the forward pumps-- CAM-3 las bombas delanteras
2104: 59
CAM-l what heading do you have CAM-l que grados tienes ahi
over there
2105:Ol
CAM-l select Kennedy on my side CAM-l pongase Kennedy en el mio
2105:04
CAM-2 Kennedy is on the number CAM-2 Kennedy esta en el numero dos pero si
two but if you want quiere comander le hago ya el radio set
cornsander I can perform the up--que ya nos estan vectoriando estamos
radio setup right now that coma con un--con el viento ya
we are now being vectored we
are like on down wind position
now
IMIRHZKPIT SPAWISH AIR-GROUID CaMllICATIlMS
TM I TIE L
s!!!momocT sa#x ss!!!mE
2105:ll
CM-1 we passed already no CAM-l ya ya pasamos no
2105:12
MU-2 yes sir CAM-2 si senor
2105:13
APPl Avianca zero five two heavy turn left heading three six zero
2105:17
ROO-2 left heading three six zero Avianca zero five two heavy
2105:22
CAM-3 three six zero CAM-3 tres seis cero
2105:24
P
CAM-2 yes comsander that's what CAM-2 si comander eso dice
he say
2105:26
CAM-l perform the radio setup but CAM-l haga el radio set up pero dejeme a mi
leave to me the VOR the in el el vor en Kennedy entonces
Kennedy then select here tell pongame aqui me dicen que
me what
2105:34
CAM-1 two what CAM-l dos que
CAM-2 two twenty three CAM-2 dos veintitres

INlRA-UKKPIT EIELISH IRTRA-tXllXPIT SPANISH AIR-SNMD CIIMHICATIONS
TIE k TM L TIE 6
z!!!!!E !i!EE!I s!!!!EEmcmcT z!!!!E !2!E!!L
2105:35
CAM ((sound of altitude alert tone))
2105:38
CAM-l two twenty three CAM-l dos veintitres
2105:39
CAM-l what heading he provide us CAM-l que rumbo nos dio ahorita
2105:42
CAM-2 non he give us three six zero CAM-2 ahorita nos dio tres seis cero
CAM-l okay
CAM-2 I am I am going to perform CAM-2 voy a voy a hater el radio set up

the radio setup on number two en el dos
CAM-l perform the radio setup CAM-1 hagase el radio set up
2105:49
CAM ((sound of landing gear warning horn))
2105:52
CAM-l hey understand that nose must CAM-l diga entiendo que entonces la nariz lo
be maintained as low as menos posible arriba si
possible yes
CAM-3 that's correct it says that the CAM-3 es correct0 dice que las banbas
forward pumps delanteras
I~-COCKPIT ER6LISH INlRA-UMXPIT SPANISH AIR-tiRWWD COHJRICATIONS
TM L TIlE I TIM 6
s!!!!!z CMTEWT
- i!!!E!zoolcmcT z!!!!EE maTEnT
-
2106:02
APPl Avianca zero five two heavy turn left heading of three zero zero
2106:04
ROO-2 left heading three zero zero Avianca zero five two heavy
2106:09
CAM-2 three zero zero on the heading CAM-2 tres cero cero en el rumbo
2106:lO
CAM-3 the forward boost pumps could CAM-3 las bombas delanteras pueden quedar
be uncovered of fuel during the descubiertas de combustible en el
go around go around
2106: 15
CAM-3 what it means it doesn't CAM-3 es decir que no tienen combustible W
m
contain fuel for feeding itself para para alimentarse y puede ocurrir
and a flameout can occur-and it un flame out entonces hay que bajar
is necessary to lower the nose la nariz nuevamente
again
2106:44
CAM-l heading three hundred CAM-l rumbo trescientos
2106:45
CAM-2 three hundred CAM-2 trescientos
IRTRA-CWKPIT EN6LISH IRTRA-COCKPIT SPANISH AIR-SWMD COHRHICATIollS
TIE I TM 6 TIE 6
sa!!E CORTEWT
- CalTERT
s!!!!EL- s!!!E!E CORTEWT
2106:51
CAM-2 right now we are proceeding to CAM-2 ya es coma si nos estan metiendo hacia
the airport inbound and we have el aeropuerto ya estamos a veintisiete
(twenty seven/seventeen) miles millas
2106:58
CAM-3 roger CAM-3 recibido
2107:04
CAM-2 this means that we'll have CAM-2 eso indica hamburguesa esta noche
hamburger tonight
2107:17
APPl Avianca zero five two heavy turn left heading two niner
2107:20
ROO-2 left heading two niner zero Avianca zero five two heavy
2107:24
CAM-2 two niner zero on the heading CAM-2 dos nueve cero en el rumbo por favor
please
2107:29
CAM-l two twenty three course counter CAM-l dos veintitres el course counter
standby the frequency no- pendiente la la frecuencia no
2107:32
CAM-2 standby for the frequency CAM-2 pendiente la frecuencia
IHlRAUKXPIT OIGLISH I~-CllCUPIT SPANISH AIR-St- -ICATIONS
TIlE L TIE & TIE 6
amTEnT
SaRcE solwxm!!E!E z!!!E !mE!!l
2107:34
CAM-l leave the ILS frequency in CAM-l deje el ILS en Kennedy hasta que yo le
Kennedy until I advise you diga ponga lo suyo alla
select your own there
2107:36
CAM-2 it is ready CAM-2 esta listo
2107:37
CAM-l well CAM-1 bueno
2107:42
CAM-2 markers are set CAM-2 10s marcadores estan puestos
2107:45
CAM-l set symmetric thrust here Don CAM-l pongame simetrico aqui Don Matri en el
Matri at the minimum minimo
2107:50
CAM-3 in the minimum I'm going to set CAM-3 en el minimo le pongo sesenta--sesenta
sixty sixty five percent y cinco por ciento
2107:56
CAM-l well do you want set it CAM-l bueno quieres emparejarlos ahi
synmietrically
2108:lO
CAM-3 sixty five CAM-3 sesenta y cinco
INiRA-COCKPIT EIIGLISH IRTRA-CaXPIT SPANISH AIR-6RfAMD CorrmICATIoWS
TIE I TIlE I TIME 6
SamE amTEnT
- H!!!!Em!E!!!L s!!!!E CMmwT
2108:34
APPl Avianca zero five two heavy descend and maintain ah descend and maintain
three thousand
2108:40
RDO-2 descend and maintain three thousand Avianca zero five two heavy
CAM-2 three thousand feet CAM-2 tres mil pies
2109:Ol
CAM-l the localizer are we going to CAM-l el localizador lo interceptamos con
intercept it with twc thousand dos mil
2109: 06
CAM-2 yes the intial approach altitude CAM-2 yes, dice que la altura initial de
is twc thousand or according to aproximacion son dos mil pies o de
the ATC acuerdo a lo que diga el ATC
2109:ll
CAM-3 they got us they are already CAM-3 ya nos tienen ya nos estan vectoriando
vectoring us
2109:21
CAM-2 they accomodate us ahead of an-- CAM-2 nos han metido por delante de un --
2109:27
CAM-l what CAM-l que
CAM-2 they accomodate us CAM-2 nos han metido

INTRA-UXXPIT ENtUSH INTRAURXPIT SPANISH AIR-6RWWD COMMICATIollS
TIME L TM L TIME 6
SmRcE UWENT -!z!!m!l !z!!!mE
2109:29
CAM-3 they already know that we are in CAM-3 es que ellos saben que ya estamos ma1
bad condition
2109:30
CAM-l no they are descending us CAM-l no a nosotros nos estan bajando
2109:35
CAM-2 one thousand feet CAM-2 mil pies
2109:36
CAM-l ah yes CAM-l ah si
2109:38
CAM-2 they are giving us priority CAM-2 nos estan dando prioridad
2109:44
APPl Avianca zero five two heavy turn left heading two seven zero
2109:47
RDO-2 left heading two seven zero
2109:50
CAM-2 two seven zero on the heading CAM-2 dos siete cero en el rumbo
2109:54
CAM-l two seventy CAM-l dos setenta
2110:03
CAM-2 it is ahead of us CAM-2 ese va adelante de nosotros
INTRA-CtRXPIT ER6LISH IRTRA-COCKPIT SPARISH AIR-GRIRMD CUWJRICATIONS
TIlE 6 TIME 6 TIE 6
UmTENT
sDlRcE =!zm!!.L s!?!!EE E!!E!!L
2110:05
CAM-3 yes CAM-3 si
2110:16
CAM-l standby for the localizer there CAM-l pendiente el localizador ahi
2110:18
2110:21
CAM-2 outer marker is seven miles CAM-2 el outer marker esta a siete millas
2110:21
APP Avianca zero five two heavy turn left heading two five zero
intercept the localizer
c,
0
2110:31 +
RDO-2 heading two five zero intercept the localizer Avianca zero five
two heavy
2110:37
CAM-2 two fifty is the heading to CAM-2 dos cincuenta es el rumbo para
intercept the localizer interceptar el localizador
2110:50
IHlRA-CfKKPIT ElltiLIsH IllT6HZWIT SPAIIISH AIR+HRMD CorrmICATIOHS
TIME & TIlE 6 TIM 6
!GlRNtcE CDNTENT s!!!l!EurmElT s!!!EE !B!m!!L
2110:56
CAM-l seventy five again Mati CAM-l sesenta y cinco nuavamente Mati
2111:oo
CAM-3 sixty five CAM-3 sesenta y cinco
2111:Ol
CAM-l six five CAM-l seis cinco
2111:04
CAM-2 this is final vector do you CAM-2 este es el vector final quiere el ILS
want the ILS commander comander
2111:07
APP Avianca zero five two heavy you are one five miles from outer
marker maintain two thousand until established on the localizer
+
cleared ILS two two left 0
w
2111:14
RDO-2 cleared ILS two two left maintain two thousand until established
Avianca zero five three heavy
CAM-3 two thousand
2111:16
CAM-l select the ILS on my side CAM-l pongame ILS en el mio
2111:20
CAM-2 the ILS in number one - one CAM-2 el ILS en el numero uno ciento diez nueve
hundred ten point nine is set nueve esta set
INlRA-WCKJ’IT OIGLISH IllTRAXlJlXPIT SpAllISH A I R - COMMICATIoI(s
TIlE I TIE L TIlE I
s!J!!m CDNTENT
- sawxarrrmrr a!!!E!I
2111:29
CAM-2 for two thousand feet CAM-2 para dos mil pies
CAM-3 localizer alive
2111:32
CAM-1 give me flaps fourteen CAM-l deme flaps catorce
2111:33
CAM-2 we are thirteen miles from the CAM-2 estamos trece millas de1 outer marker
outer marker
CAM-2 flaps fourteen CAM-2 flaps catorce
2111:44
CM ((sound of trim in motion horn))
2111:47
CAM-l navigation number one
2111:49
CAM-l did you already select flaps CAM-l ya le pusistes catorces de flaps no
fourteen no
2111:51
CAM-2 yes sir are set CAM-2 si senor estan set
2111:53
CAM-2 navigation number one
IWTRA-COCKPIT ENIUSH IRTltA-CUXPIT SPANISH AIR-UtWWD CUMHICATI~S
TM 6 TIRE 6 TIME 6
SaNKE COWTERT -!z!!!!m WlllEcE a!!!Im
2111:55
APPI Avianca zero five twc heavy speed one six zero if practical
2111:57
CAM-3 fourteen
2111:59
RDO-2 one six zero Avianca zero five two heavy
2112:05
CAM-l give me flaps twenty five CAM-l deme veinticinco de flaps
2112:06
CAM-2 flaps twenty five
2112:07
CAM ((sound of trim in motion horn))
2112:09
CAM-2 reduce to a minimum CAM-2 reduction al minimc
2112:ll
2112: 15
CAM-2 we have a traffic ahead of us CAM-2 tenemos un trafico adelante
IRTRA-CDCKPITERIXISH IRTRA-CDLXPIT SPARISH AIR-UNRMD CMUMICATIDNS
TIE 6 TIlE 6 TIE 6
zE!Ez !zYE!!E s!!!.EEw s!!!!!a B!!E!!L
2112:18
CM ((sound of trim in motion horn))
2112:28
CAM-l we can maintain one hundred and CAM-l podemos mantener ciento cuarenta con
forty with this flap setting estos flaps
2112:41
CAM ((sound of trim in n&ion horn))
2112:42
2112:47
2112:51
2112:52
CAM-l how many miles is that thing CAM-l cuantas millas esta la vaina esa
located
2112:53
CAM-2 it is at seven miles cotnnander CAM-2 esta a siete millas canander estamos
and we are at ten miles at a diez millas en el manento--de1 outer
the moment fran the outer marker marker
IRTRA-COCKPIT ER6LI!9l I-IT SPARISH AIR-6RfNMD CorrrmICATIOMS
TIE L TIE I TIlE 1
SamE CDNTENT -saNlcEmRTERT - !z!!Im
2113:03
2113:25
CAM-1 reset frequency the ILS please CAM-1 resetieme frecuentemente el ILS por
favor
21113:29
CM-2 okay
2113:36
CAM-l do it CAM-1 hagamele
2113:34
CAM-l thank you
2113:47
CAM-2 now the course is going to be CAM-2 ya el course intercepta en el outer
intercepted at the outer marker marker o sea que no hay problema
this means that problem comander
2114:00
CAM-2 localizer to the left
2114:17
IRTRA-COCKPIT ER6LISH IWIT SPARISH AIR-UtOUIY) ClRWMICATIolls
TIE k TM I TIlE I
amTENT
SaNIcE s!!!!EB!!E!!I s!!!E a!!m!I.
2115:08
APPl Avianca zero five two heavy contact Kennedy tower one one niner
point one good day
2115:12
RDO-2 one one niner point one so long
2115: 19
RDO-2 Kennedy tower Avianca zero five tw heavy established two two
left
2115:23
TM Avianca zero five two heavy Kennedy tower two two left you're
number three following seven tw seven traffic on a ah niner mile
final ,
2;
q
2115:32
RDO-2 Avianca zero five tw roger
2115:34
TM? Clipper four seventy four what's you're airspeed now
2115:37
PAA one forty five
2115:38
TUR American six ninety tw traffic ahead four miles is one forty
five knots airspeed
I
108
L
MTRA-CDCKPIT ER6LIStl IIITRA-COCI(PIT SPARISH AIR-GRWWD CllMMICATIoI(S
TIE & TIW L TIME 6
s!!!Bz UMTENT =e!!E!!L %!!!!a sa!E!!L
2116:Ol
TUR US Air hold short of two two right
2116:03
USA117 holding
2116:07
2116: 19
CAM-l can I lower the landing gear yet CAM-1 no le puedo bajar las ruedas todavia
2116:21
CAM-2 no I think it is too early now CAM-2 no todavia yo creo que es muy apre
surado
2116:26
CAM-l it is at the minimum in order CAM-1 es muy en el minimo para volar
to fly twenty five veinticinco
2116:33
CAM-2 yes CAM-2 si
2116:37
2116:41
TUR USAir one seventeen cross two two right taxi right on the outer
ground on one two one point eight on the other side
INtRA-ClKKPIT OIGLIUI IHlRA-WCKPIT SPANISH AIR-UWAD UHHWCATIolls
TM I TIM L TIN! 6
CMmwT -sDutcEalmERT- s!!!!!G c(wITEIIT
2116:46
USA117 cleared to cross one eight nine you say
2116:49
TM no one two one point niner
2116:52
USA117 gunna say is that a new one thanks alot cleared to cross USAir
one seventeen
2116:53
CAM-2 if we lower the landing gear we CAM-2 si bajamos las ruedas nos toca
have to hold very high nose subir mucho la nariz
attitude
CAM-3 and it is not very--- CAM-3 y no es muy-- c,

0’
2116:56
TUR American six ninty two runway two two left wind one niner zero at
two one cleared to land
2117:Ol
ML692 cleared to land American six ninty two
2117:17
TUR Avianca zero five two what's your airspeed
2117:20
RDO-2 Avianca zero five two one four zero knots
IRTRA-COCKPITEIRUSH IRTRA-CUXPIT SPARISH AIR-WRMI -ICATIoWS
TIE I TIlE L TIlE I
CaTERr
SDIRCE s!!EsOOlCCOlT s!!!!z !am!!!L
2117:25
CAM-l they was asking for the CAM-1 al American es que le preguntaban
American
2117:30
TUR Avianca zero five two can you increase airspeed one zero knots
2117:36
ROO-2 ah say again the speed
2117:37
TUR can you increase you airspeed one zero knots
2117:40
CAM-1 one zero
2117:41
RDO-1 okay one zero knots increasing
2117:42
TYR increase increase
2117:42
CAM-l what CAM-l que
2117:44
RDO-2 increasing
IRTRA-COCKPIT ER6LISH IRTRAUtCKPIT SPMISH AIR-GRWWD ColllJllICATIollS
TIM L TIE I TIE 6
CDNTENT
SamE s!!!!z!z!!!!m H!!!!!z amTERT
-
2117:45
CAM-l what CAM-1 que
2117:46
TUR okay
CAM-3 ten knots more CAM-3 dies nudos MS
2117:4a
CAM-2 ten little knots more CAM-2 diez nuditos mas
CAM-3 ten little knots more CAM-3 diez nuditos mas
CAM-l one hundred and fifty CAM-1 ciento cincuenta
2117:52
CAM-l here we go CAM-l ahi estamos bien
2117:55
CAM-l tell me things louder because-- CAM-1 digame un poquito mas duro las vainas--
I'm not--hearing it porque es que no--no las estoy oyendo
2iia:u
CAM-2 we are three miles to the outer CAM-2 estamos tres millas de1 outer marker
marker now ahora
2iia:i3
CAM-l right
INTRA-CDCKPIT ERIXISH IRTRA-CNXPIT SPARISH AIR-WNMD CorrmwICATIDNS
TIME L TIE L TIRE 6
CDNTENT
m.aKE soIwxuwrmcT SDum CDNTERT
-
2118: 15
CAM-1 resetting the ILS CAM-l resetiando el ILS
2118: 16
TUR Clipper four seventy four turn right taxi via juliet hold short
of two two right remain on frequency
2118: 17
CAM-2 here it is already intercepted CAM-2 aqui ya lo intercept0
2118:24
2118:27
PAA Clipper four seventy four roger
2118:32
CAM-2 glide slope alive
2118:37
2118:38
CAM-l I’m going to approach at one CAM-l voy a aproximar en ciento cuarenta
hundred and forty it is what he es que quiere 0 cuanto es que quiere
wants or what is the value he
wants
IRTRA-COCKJ’IT OIGLISH IRTRAXOCKPIT SPAMSH AIR-6RWIID MrrrrmICATIMlS
TIE I TM I TIE L
amTEnT
SamE s!!!smmrr s!!!!% !mE!!l
2118:41
CAM-2 one hundred and fifty we had one CAM-2 ciento cincuenta ibamos a cientro cuarenta
hundred and forty and he y el quiera diez nuditos mas
required ten little knots more
2118:54
2118:57
TUABOl Kennedy tower TWA eight zero one heavy is twelve point two on the
DME
2119:oo
TUR TWA eight oh one heavy Kennedy tower roger number three on the
approach following heavy seven oh seven traffic ah four and a c
half miles ahead he's indicating Len knots less on the ground p'
speed there's a wind shear reported loss * gain and loss of ten
knots seven hundred feet to the surface by a DC-9 runway two two
left RVR more than six thousand
2119:09
CAM-l lower the gear CAM-l bajeme las ruedas
2119:lO
CAM-2 gear down
2119:la
TWA801 ah thank you sir
INlRA-CDCKPIT EIIGLISH I - I T SPARISH AIR-6RWWD CDWMICATIDRS
TIME I TIWE L TM L
amTERT
SDIRCE z!EE(301cmcT SOIWX !2!!E!E
2119:21
CAM-1 give me forty CAM-l deme cuarenta
2119:22
CAM-2 forty CAM-2 cuarenta
2119:23
CAM-l ah symmetric please CAM-l ah simetrico por favor
2119:25
CAM-l sixty five percent or whatever CAM-l sesenta y cinco o lo que tenga ahi
you have close to it cerca
2ii9:2a
2119:30
CAM-1 mode selector approach landing
checklist
2119:32
CAM-3 landing check
2ii9:38
2119:40
IRTRA-CWKPIT ER6LISH IRTRA-URXPIT SPARISH AIR-WtOUWD MrrmwICATIOUS
TIlE L TIE I TIE 6
a!!!E !!?!E!L s!!!!!E!z!!m!l z!!!!!E !z!!E!E
2119:41
CAM-3 speed brake lever
2119:42
CAM-1 full forward
2119:43
CAM-3 spoiler switches
2119:45
CAM-2 on
CAM-3 on
2119:46
CAM-3 engine start control selectors
on
2119: SD
CAM ((engine igniter sound starts and continues until end of tape))
2119:56
CAM-3 no smoking switch on
2119:57
CAM-2 on
IMRA-CDCKPIT ER6LISH IRTRA-CDLXPIT SPARISH AIR-UWIMD CDWMCATIDM
TIlE 6 TIlE L TIM! 6
iscn%KE
- COWTENT
- CDRTERT
s!!!!EE- s!!!EE !z!E!!l
2119:58
TWR Avianca zero five two two two left wind one niner zero at two
zero cleared to land
2120:oo
CAM-3 gear
212O:Ol
ROO-2 cleared to land Avianca zero five two heavy
2120:03
RDO-2 wind check please
212O:OS
TM one niner zero at two zero
2120:07
RDO-2 thank you
212o:oa
CAM-2 one hundred and ninety with CAM-2 ciento novento con veinte esta
twenty is in the wind el viento
212O:lO
CAM-l with what CAM-l con que
212O:lD
TWR Avianca zero five two say airspeed
IRTRA-CDCKPIT EKLISH IRTRA-UICKPIT SPARISH AIR-SURMD MrrrmwICATIDRS
TIE L TIME L TIM! 6
CDNIERT
SanKE 3!!!E!x!iM!H!I s!i!!EE !z!E!!L
CAM-2 with twenty CAM-2 con veinte
2120: 12
RDO-2 zero five two is ah one four five knots
2120: 15
TUR TYA eight oh one heavy if feasible reduce airspeed one four five
2120:17
CAM-1 give me fifty CAM-l deme fifty
2120: 19
TWA801 okay we'll do our best
2120: 19
2120:21
CAM-1 are we cleared to land no CAM-l ya nos dio libre atterrizar no
2120:23
CAM-2 yes sir we are cleared to land CAM-2 si senor estamos autorizados a aterrizar
2120:25
CAM-3 hydraulic pressure quantities
normal
IRTRA-COCKPIT DIGLISM IHIRA-COlXPIT SPARISH AIR-H!- cOrrrmICATIolls
TIE L TIM I TIE L
SolRn E!!E!!x =mrmrr SaREE !HE!!I
2120:28
CAM-2 localizer to the left slightly
below glide slope
2120:33
CAM-3 stand by flaps fifty landing
checklist complete
2120:36
CAM-2 stand by flaps fifty
2120:39
CAM-l give me fifty CAM-1 dema cincuenta
2120:40
CAM-2 flaps fifty now
2120:41
CAM-3 fifty green light final set
2120:42
2120:45
CAM-3 all set for landing
2120:48
CAM-2 below glide slope
-
INlRA-CXKXPIT ER6LISH INTRA-UICKPIT SPARISH AIR-GRWWD CDMlRICATIowS
TIlE L TIlE I TIE 6
!xmcE CDNIERT s!!!!!zcmac z!!!!e CUTERT
-
2120:53
TUR TWA eight oh one heavy if feasible reduce you to final approach
airspeed at this time
2120:56
TUABDl yes sir we're indicating one five zero now that's about the best
we can do
2121:06
CAM-l confirm the wind CAM-l me confinna et viento
2121:07
TUR Avianca zero five two heavy can you increase your airspeed one
zero knots at all
2121:09
RDO-2 yes we're doing it
2121:12
TWR okay thank you
2121:13
212l:lS
CAM-1 confirm the wind CAM-l confirmame el viento
a
IRTRA-CIRXPIT EIELISH IRTRA-CtJlXPIT SPARISH AIR-UNWO -1CATIolls

TIE I TIlE L TIM! 6
SCRRCE amTERT s!!!!!zs!!!E!a s!!!Ez !mE!!E
2121:16
CAM-2 the wind is one hundred ninety CAM-2 el viento esta de ciento noventa con
with twenty knots veinte
2121:20
CAM-1 I got it CAM-l esa vaina
2121:30
TWR TWA eight oh one you're gaining on the heavy seven oh seven turn
left heading of ah one five zero and ah maintain two thousand
2121:35
CAM-l I’m going to leave the runway CAM-l voy a dejar la pista por la derecha ok
to the right okay
2121:36
CAM-2 to the right yes sir CAM-2 por la derecha si senor
2121:38
TWA801 okay TWA eight oh one heavy left to one five zero maintain two
thousand
2121:41
CAM-l localizer glide slope one CAM-l localizer glide slope mil pies
thousand feet stand by for pen diente lutes
lights
2121:46
CAM-2 standing by for lights CAM-2 pendiente todavia lutes
I
122
IRTRA~IT EIELISH IMRA-CUDIT SPANISH AIR+ROlHD #rrrmICATIWS
TIE L TIN L TIlE L
B!!E!!I s!z!!EE!!!!!lm s!!E mE!!!I
2122:09
2122: 10
CAM-~ instruments cross checked
slightly below
2122: 13
PAA Clipper four seventy four cleared to cross
2122315
TUR TWA eight oh one contact approach one one eight point four
2122: 17
CAM-2 all set for landing
2122: 19
CAM-3 stand by for lights CAM-3 pendiene lutes
2122:21
CAM-l stand by CAM-l pendiente
2122:22
TWA801 eighteen four TWA eight oh one
2122:24
TVR American six ninety two taxi via juliet hold short two two right
remain this frequency
IRTRA-COCKPIT EIELISH IRTRA-COm’IT SPAMSH AIR-6RWWD CIHWIMICATI~S
TIE & TIlE L TIM! 6
sama! amTERT -!z!E!!I z!!!!!z !Y!E!!I
2122:26
CAM-2 the wind is slightly from the CAM-2 el viento esta ligeramente a la
left one hundred ninety with izquierda ciento noventa con veinte
twenty
2122:28
AAL hold short two two right American six ninety two
2122:33
AAL Tower American forty heavy's with ya outside LORRS
2122:36
TUR American forty heavy Kennedy tower roger runway two two left
you're number two following heavy seven oh seven traffic on a two
mile final wind two zero zero at one eight RVR five thousand five
hundred cleared to land
2122:44
CAM-2 below glide slope
2122:50
AAL cleared to land American forty heavy
2122:52
CAM-2 glide slope
2122:56
TUR American forty heavy what's your airspeed
INTRA-IT ER6LISR IRTRA-CWKPIT SPARISH AIR-SNRRtD -1CATIORS
TIE L TIRE I TIlE 6
!sRRcE CDRTERT z!!!!!z!!!!m!x s!!!!sE iz!m!L
2122:57
CAM-2 this is the wind shear CAM-2 es el wind shear
2123:00
AAL ah one sixty American forty heavy
2123:03
TWR roger ah can you increase it one zero knots
2123‘: 06
AAL afirm
2123:07
TWR appreciate that
2123:08
CAM-3 glide slope
6PWS whoop whoop pull up
2123:09
CAM-2 sink rate 'CAM-2 rata de descend0
2123:lO
CAM-2 five hundred feet CAM-2 quinientos pies
2123:ll
GPWS whoop whoop pull up
IRTRAiXlCKPIT ER6LIsH I-IT SPARISR AIR- cOrrmICATIolls
TIM & TIE I TIE I
s!z!EE. !mE!!!L s!!!B!xoQcim z!!B!z B!!mL
2123:12
2123:13
CAM-1 lights CAM-1 lutes
2123:14
2123:15
2123:17
2123:18
2123:20
CAM-l where is the runway CAM-1 donde esta la pista
2123:21
2123:22
GPWS whoop whoop pull 'up
IRTRA4OCKPIT EIELISH IRTRA-COCKPIT SPANISH AIR-UtWWO cOrrmICATIW!5
TIE & TIE L TIlE L
%!!BE ‘UmTERT
- sw!!E!z!!!Im SQREE !i!m!!L
2123:23
2123:23
CAM-l the runway where is it CAM-1 la pista donde esta
2123:25
GPWS glide slope
2123:26
GPWS glide slope
2123:27
CAM-2 I don't see it I don't see it CAM-2 no la veo no la veo no la veo
2123:28
CAM-l give ma the landing gear up CAM-l deme--subama las ruedas subama las
landing gear up ruedas
GPWS glide slope
2123:29
GPWS glide slope
2123:32
CAM ((sound of landing gear warning horn))
I
128
E
e
IKIRA-ClNWIT ER6LISH IRTRA-COCKPIT SPARISH AIR-WRMD COMAICATIMIS
TIlE & TIRE L TIWE 6
z!!!!KE CDRTERT %!!!KEl!!!m!x s!!!!!E B!!E!!L
2123:54
CAM-l flaps twenty five CAM-l flaps veinticinco
2123:54
CAM-2 two thousand feet CAM-2 dos mil pies
CAM-3 flaps twenty five CAM-3 flaps venticinco
2124:00
CAM-l I don't know what happened CAM-l flaps venticinco yo no se que paso con
with the runway I didn't la pista oye no la vi
see it
CAM-3 I didn't see it
CAM-2 I didn't see it
2124:04
TWR Avianca zero five two you are making a left turn correct sir
2124:06
CAM-l tell them we are in emergency CAM-l digale que estamos en emergencia
CAM-3 two thousand feet CAM-3 dos mil pies
2124:08
ROO-2 that's right to one eight zero on the heading and ah we'll try
once again we're running out of fuel
IRTRA-aKKPIT DIGLIW INTRA-ClNXPIT SPARISH AIR-UtCRMD -1CATIORS
TIE L TIllE L TIE 6
z!!!!!s CwlERT
- s!!!!!z!z!!!mE SolRn !u!E!!l
2124:14
2124:15
TUft okay
2124:17
CAM-l what did he say CAM-l que dijo
2124:18
CAM-2 maintain two thousand feet one CAM-2 mantener dos mil pies ciento ochenta
eight on the heading I already en el rumbo ya le dije que intentamos
advise him that we are going to de nuevo porque ya no podemos
attempt again because we now we
can't
2124:21
TVR American forty heavy two two left wind two zero zero at one niner
w'
cleared to land wind shear reported gain and loss of ten knots 0
seven hundred feet to the surface by a DC-9
2124:22
CAM-l advise him we are emergency CAM-l digale que estamos en emergencia
2124:26
CAM-l did you tell him CAM-l ya le dijo
2124~27
AAL American forty
IMRAXOCKPIT ERWSH IRTRA-IT SPANISH AIR-tiRWWD COMMICATIollS
TIE & TIE I TIE IL
mcE B!!E!!I -E!!!!!m s!!!E !z!!!mL
2124:28
2124:29
CAM-2 I already advised him CAM-2 ya le dije
2124:31
CAM-l flaps four--fifteen CAM-l flaps ca--quince
2124I32
TWR Avianca zero five two heavy continue the left turn heading one
five zero maintain two thousand
2124:36
RDO-2 one five zero maintaining two thousand Avianca zero five two
w
Y
heavy c1
2124339
TUR Avianca zero five two heavy contact approach on one one eight
point four
2124:40
CAM-2 one hundred and fifty on the CAM-2 ciento cincuenta en el rumbo
heading
2124:42
RDO-2 one one eight point four
IRTRA-CXUXPIT ERFLISH IRTRA-ClXKPIT SPARISH AIR-GRWIID -1CATICMS
TIE & TM L TIlE A
s!!E!z CONTENT
- z!!!!EEnmElcT !z!m!!l
2124:45
CAM-l they put us to reduce airspeed CAM-1 es que lo ponen a rebajar
that's the thing man hundred velocidad y toda esa vaina hombre
and fifty ciento cincuenta
2124:50
CAM-2 one hundred and fifty on the CAM-2 ciento cincuenta en el rumbo
heading
2124:51
APP five forty two heavy thank you four your help contact Kennedy
tower one one niner point one
2124:52
2124:53
TWA542 good day thank you
2124:55
CAM-l flaps fifteen
2124:55
RDO-2 approach Avianca zero five ah two heavy we just missed a missed
approach and ah we're maintaining two thousand and five on th-
2124:58
CAM-3 flaps fourteen CAM-3 flaps catorce
IRTRA-COCKPIT ERfUsH I-IT SPANISH AIR-GRWWD C4WURICATIoI(s
TIlE li TIM! li TIlE 6
UMIERT
SamE s!!!!EE!z!E!!I iz!!!IE
2125:00
CAM-l flaps fourteen CAM-l flaps catorce
2125:07
APP Avianca zero five two heavy New York good evening climb and
maintain three thousand
2125:08
CAM-1 advise him we don't have CAM-l digale que no tenemos combustible
fuel
2125: 10
RDO-2 climb and maintain three thousand and ah we're running out of
fuel sir
2125:12
APP okay fly heading zero eight zero
2125: 15
RDO-2 flying heading zero eight zero climb to three thousand
2125: 19
CAM-2 three thousand feet please CAM-2 tres mil pies por favor
2125: 19
APP TWA eight zero one heavy turn left heading zero four zero
IRTRA-UKXPIT OIGLISH I-ITSPANISH A I R - COMRJNICATIORS
TIE 6 TIM! 6 TM 6
UMTERT
SaRcE s!!!!!zB!!!m!E E!!E!!l
2125:20
CAM-l what zero eighty CAM-1 cero que ochenta
CAM-2 hundred and eighty CAM-2 ciento ochenta
2125:22
CAM-l ah
2125:22
TM zero four zero TWA eight oh one heavy
CAM-2 hundred and eighty CAM-2 ciento ochenta
2125: 28
CAM-l did you already advise that CAM-l ya le dijiste que no tenemos
we don't have fuel combustible
2125:29
CAM-2 yes sir I already advise him CAM-2 si senor ya le dije ciento ochenta
hundred and eighty on the heading en el rumbo mantenemos tres mil pies
we are going to maintain three y nos va a volver a meter
thousand feet and he's going to
get us back
CAM-1 okay CAM-1 bueno
2125:41
APP Evergreen one zero two heavy fly two seven zero
IRTRA-UJCKPIT Ell6LISH I-IT SPARISH AIRe C4lMMCATIolls
TIE 6 TIN 6 TIIE 6
z!!!!!z !z!!Im. s!!!!!Em!E!!!l SolRQ E!!E!!L
2125~44
ELAlOP two seven zero one oh two heavy
2125:47
CAM-2 one hundred and eighty CAM-2 ciento ochenta
2125:50
CAM-1 give me bugs CAM-1 dem el bug
2125:52
CAM-2 one eighty on the heading CAM-2 ciento ochenta en el rumbo
2125:53
APP American four heavy present heading I'll give you a turn here in
a minute t;
ul
2125:54
CAM-1 give me bugs CAM-l dema el bug
2125:56
ML40 knerican four heavy wilco
2125:58
2126:00
CAM-2 three thousand feet CAM-2 tres mil pies
IHTRA-CDCKPIT ER6LISli IRTRA-CaXPIT SPAUISH AIR-fiRWWD -1CATIoWS
TIIE 6 TIN 6 TIlE 6
amTERT
SaRcE folRcE!!!!!EE B!!!EE UmERT
-
2126:Ol
2126:07
APP American four heavy turn left heading one eight zero you're nine
miles from outer marker maintain two thousand until established
on the localizer cleared for ILS two two left
2126:ll
CAM-2 *
2126:15
AAL okay one eight zero two thousand maintain two until established
cleared ILS two two left American four heavy
2126:21
CAM-l okay CAM-l bueno
2126:21
APP Evergreen one zero two heavy descend and maintain three thousand
2126:24
ELAlOL okay leaving four for three Evergreen one two heavy
2126:27
APP Avianca zero five two heavy turn left heading zero seven zero
2126:31
RDO-2 heading zero seven zero Avianca zero five two heavy
137
IRTRAVIT E116LISH IHIMXORPIT SPARISH AIR-6ROWl UrrrmICATIolls
TIE 6 TIllE 6 TIE 6
s!!!!m cG!?!EE -G!m!!L z!!!!z !am!!I.
2126:52
CAR-2 zero seven zero on the heading CAR-2 cero siete cero en al rumbo
maintaining three thousand feet manteniendo tres ail pies
2126:59
ELAlO2 * cleared for the approach Evergreen zero two heavy
2127:02
APP TWA eight zero one heavy turn left heading two nine zero
2127~03
CAR-1 give me the Kennedy ILS in CAM-l deme el ILS de Kennedy--en el uno
number one
2127:04
TWA801 two nine zero TWA eight oh one
2127 : 08
CAM-2 the ILS or the VOR CAM-2 el ILS 0 el VOR
2127:09
CAM-1 i like say the VOR CAM-1 el VOR digo
2127:ll
CAM-2 fifteen point nine is on number CAM-2 quince nueve esta en el numero uno
one
2127: 13
CAR-1 zero ninety CAM-l cero noventa
139
3
F
al
.rc
IWlRA-CDCKPIT EN6LIStl IRTRA-IT SPANISH AIR-WlUND CIIMURICATIORS
TIME 6 TIE 6 TIME a
s!!!R UIRTENT
- s!!!!!Bw s!B!EE UmTErrr
212?:35
APP thank you
2127:36
CAM-l to die CAM-l a morir
2127:38
PAA Kennedy approach Clipper eighteen twelve heavy with alpha's
descending to five thousand heading zero six zero
2127~43
APP Clipper eighteen twelve New York good evening
2127:52
APP TWA eight zero one heavy turn left heading two seven zero
2127:54
TWA801 two seven zero TWA eight zero one heavy
2128:lO
2128:ll
APP Clipper eighteen twelve heavy descend and maintain four thousand
2128:lS
PAA Eighteen twelve heavy to four thousand
INlRA-COCKPIT ElRiLISH INlRA-IT SPANISH AIR-tXOURD -ICATIONS
TIE 6’ TIE 6 TIE 6
SDUKE CDNTERT s!!!!!z!B!m!l SaRcE CONTENT
-
2128:16
CAM-l take it easy take it easy CAM-l tranquil0 tranquil0
2128:Zl
2128:42
ELA102 ah approach for Evergreen one oh two heavy is one seven zero a
good speed on final
2128:47
APP ah what's it gunna be in knots ah I don't know the MACH ah
2128:48
2128:54
ELAlOE ah yes sir a hundred and seventy knots on final for Evergreen is
that okay
2128:55
2128:56
IKIRA-COCKPIT E66LISH IHlRA-C4N%PIT SPARISH AIR-6ROUID COMJRICATIORS
TIlE 6 TIlE 6 TIDE 6
z!!!!!z CwrERT
- s!!!e.E!!E!!l CDRTERT
2128:58
APP yeah that's fine ah I have a heavy jet seven ahead and he's about
twenty knots slower that's due to the winds I'm gunna need you to
slow twenty knots in three or four miles
2129:09
ELA102 okay sir
2129:ll
RDO-2 ah can you give us a final now Avianca zero five two heavy
2129:zo
APP Avianca zero five two affirmative sir turn left heading zero four
zero
2129:24
CAM-l zero four zero CAM-l cero cuatro cero
2129:25
RDO-2 zero four zero Avianca zero five two heavy
2129:30
CAM-l give me a bug CAM-l deme bug
2129:33
CAM-2 zero four zero okay that's fine CAM-2 cero cuatro cero okay ahi esta bien
2129:36
CAM-2 I'm giving you bugs for- CAM-2 ahi le estoy dando bugs para--
!il
Ec
0
%
2
e
I6lRA-COCKPIT EN6LISH IKlR6-COCKPIT SPANISH AIR-CNRMO caMlwICATIoWS
TIlE 6 TIlE 6 TIE 6
UmTEKr
SanKE a!!!!E MllTElcT s!!!!!z CDRTERT
-
2130:44
APP okay turn left heading three one zero sir
2130:47
RDO-2 three one zero Avianca zero five two
213O:SO
CAM-l tell me- CAM-l digame
2130:50
APP Clipper eighteen twelve heavy turn left heading three one zero
2130:52
PAA eighteen twelve heavy left three one zero
2130:52
CAM-2 three one zero in the-- CAM-2 tres uno cero en el
2130:53
CAM-l flaps fourteen CAM-l 10s flaps catorce
2130:54
CAM-2 three one zero CAM-2 tres uno cero
CAM-3 no sir are in-- CAM-3 no senor estan en

IRTRA-CUCKPIT EIELISH I-ITSPANISH AIR-UtWllD -1CATIoIIS
TIE 6 TIlE 6 TIE 6
amTERT
SaRcE saRalz!!B!E a!!!!z m!Im
2130:55
CAM-l set flaps fourteen CAM-l pongame catorce
2130:55
APP and Avianca fifty two fly heading of three six zero please
2130:56
CAM-2 fourteen degrees CAM-2 catorce grados
CAM-1 tell me heading what CAM-1 digame el rumba cual
2130:58
RDO-2 okay we'll maintain three six zero now
2130: 59
CAM-3 three six zero now CAM-3 tres seis cero ahora
2131:00
2131: 01
APP okay and 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
2131:07
RDO-2 okay we're number two and flying three six zero now
IRTRA-CKKPIT ER6LISH IRTRA~IT SPANISH AIR-6RfMMl MrrrmICATIolls
TIlE 6 TIE 6 TIM! 6
CDHTEWT
SaRcE s!!!!!s!z!!m!l s!EE m!E!!l
2131:lO
APP thank you sir
2131:lZ
CAM ((sound of altitude alert chime !)I
2131:ZO
CAM ((sound of trim in motion horn)
2131:22
CAM-l three sixty no CAM-l tres sesenta no
2131:23
CAM-2 three sixty CAM-2 tres sesenta
2131:25
2131:26
CAM-1 flaps fourteen CAM-l flaps catorce
2131:27
APP TWA eight zero one heavy you're eight miles behind a heavy jet
contact Kennedy tower one one niner point one thanks for the help
2131:33
IRTRAUNXPIT EMiLISH IRTRA-CDUCPIT SPARISH AIR-GRMIWD CUWRICATIDRS
TIE 6 TIWE 6 TIE 6
s#RcE cxmTENT
-. -saaccEaJmEnT- z!!!!s !z!E!!I
2131:33
TWA801 okay eight oh one roger and what's his ground-what's his airspeed
do you know
2131:36
APP ah he's indicating ten knots slower eight miles
2131:38
CAM ((sound of trim in motion horh))
2131:39
TWA801 okay thank you
2131:42
APP thank you
2131:45
z
APP Clipper eighteen twelve heavy speed one six zero if practical 00
2131:47
PAA Eighteen twelve heavy slowing to one fifty
2132:08
APP Avianca zero five two heavy turn left heading three three zero
2132:ll
RDO-2 three three zero on the heading Avianca zero five two
IRTRA-CDCKPIT EKLISH I6TRA-CDCKPIT SPANISH AIR-UWMD -1CATIlMS
TIE 6 TIME 6 TIE 6
s!B!!!z c!m!!l -&!!!m!E s!!!!KE CcmTEKr
-
2132: 14
CAM-2 three three zero the heading CAM-2 tres tres cero el rumba
2132:37
2132:38
((sound of momentary power interruption to the CVR))
2132:39
CAM-3 flame out flame out on engine CAM-3 se apagaron--se apago el motor cuatro
number four
2132:41
((sound of momemtary power interruption to the CVR))
2132:42
CAM-l flame out on it CAM-l se apago
2132:43
CAM-3 -flame out on engine number CAM-3 se apago el motor tres essential en
three essential on number number one--e1 dos--en el uno
two on number one
IRTRA-CDCKPIT ER6LIStl IRTRA-UNXPIT SPARISH AIR-fiROUID CDMURICATIDRS
TM 6 TIE 6 TIE 6
SamE G!!!E!L s!!!!!B~ !z!!!Im
2132:49
CAM-l show me the runway CAM-l muestreme la pista
2132:49
RDO-2 Avianca zero five two we just ah lost two engines and ah we need
priority please
2132:54
APP Avianca zero five two turn left heading two five zero intercept
the localizer
2132:56
CAM ((sound of engine spooling down))
2132:57
CAM-2 two five zero CAM-2 dos cinco cero
2132:59
RDO-2 roger
2133:00
CAM-l select the ILS CAM-l pongame el ILS
2133:Ol
CAR-2 ILS
2133:03
CAM-2 it is on the number - two CAM-2 esta en el numero dos
INTRA-CaXPIT EIIKISH INlR6~IT SfWISH AIR4RWIO COMJNIC6TIolls
TIE 6 TIN 6 TIlE 6
%!!E E!!E!!L s!!!EEarrmrr samx -cDRTERT
2133:04
CAM-l select the ILS let's see CAM-1 pongame el ILS haber
2133:04
APP Avianca zero five two heavy you're one five miles from outer
marker maintain two thousand until established on the localizer
cleared for ILS two two left
2133: 12
RDO-2 roger Avianca
2133:14
APP Clipper eighteen twelve turn left heading two two zero
2133:lS
CAM-1 that no--that CAM-l que no--que
2133: 18
PM1812 Clipper eighteen twelve left two two zero
2133:22
CAM-l did you select the ILS CAM-1 ya me pus0 el ILS
2133:23
CAM-2 it is ready on two CAM-2 ya esta listo--el dos
2133:24
((end of recording))
152
APPENDIX C
FAA TRAFFIC IMANAGEMENT
ATC Central Flow Control
The ATC Central Flow Control Facility (CFCF) in Washington, D.C.,

monitors airport flow programs nationwi de. On the evening of the act ident,
an expanded quota flow program to restrict traffic was in effect for JFK
airport. All operating positions at the CFCF are linked through a
communications system, including an Apollo computer, to all ATC facilities.
Normally, the workload is distributed to specialists at the CFCF by dividing
the country into five geographical areas, the northeast, southeast, north
central, south central and west. A specialist is assigned to each area.
However, the sectors can be broken down in order to best accommodate the
system.
One of the tools available to CFCF specialists for monitoring

traffic is the aircraft situation display (ASD). Each specialist also
maintains direct contact with the facilities in his or her area. At the end
of a shift, a specialist can retrieve a Verification and Analysis Report from
the computer to determine the effectiveness of a given program.
When the supervisor came on duty on the evening of January 25,

1990, the shift was fully staffed with seven or eight specialists. He stated
that there were 10 traffic management programs already in effect, described
as "a little high," because of the number of ground delay programs in effect
that evening. The supervisor assigned specialists to airports determined to
require special attention instead of assigning them by geographical
boundaries, as follows: one specialist to Boston and the rest of the
northeast, one specialist to LaGuardia and Newark Airports, one specialist to
JFK and Philadelphia, one specialist to Chicago's O'Hare Airport, one
specialist to the west, one specialist to the southeast, and one specialist
to the south central United States.
From a weather briefing, the supervisor learned that a weather

system existed that was affecting the air traffic system. It extended from
the Gulf of Mexico to New England. The JFK traffic management program had
been implemented between 0900 and 1000 and was intended to reduce the number
of airplanes arriving each hour at JFK Airport beginning at 1400.
The acceptance rate of 33 airplanes per hour was established for

the JFK program. The day watch supervisor had discussed with the NY TRACON
traffic management specialist weather problems that New York area airports
were expected to encounter throughout the day.
With regard to the JFK traffic management program, international

flights were exempt from being placed on ground delays at their departure
airports. Therefore, in order to implement the program effectively,
available arrival slots were established for international fl,ights by placing
a sufficient number of US domestic flights on ground delays.
153
FAA order 7210.47A, Traffic Management System Handbook, states

that the purpose of a ground delay program is to maintain acceptable traffic
levels and/or limit airborne holding within an arrival center or approach
control area.
In addition, certain domestic airports can be exempt from ground

delays for flights departing JFK because of unique situations at those
departure airports. Chicago's O'Hare and Midway Airports are sometimes
exempt from a ground delay program due to congestion and limited ramp space.
It is the decision of the CFCF shift supervisor whether to exempt certain
airports from a ground delay program. On January 25, 1990, O'Hare and Midway
Airports were exempt from the JFK ground delay program.
Since runway 22 left was the only operating runway at JFK, a

landing rate of 33 airplanes per hour was considered permissible. Around
1630, the weather at JFK had become worse than previously forecast. The
airborne inventory of airplanes increased because of missed approaches, and
it became necessary to implement ground stops, for intermittent periods, for
the rest of the evening.
When the CFCF becomes aware of information that affects the system
or a particular airport, an advisory is sent through Aeronautical Radio,
Inc., (ARINC) to inform users about the situation. ATC facility traffic
management units make every effort to keep the CFCF advised of problems and
delays. If the facilities do not provide information, no data can be
disseminated by the CFCF to the users. It was usual practice that a
30-minute airborne delay would prompt CFCF action to adjust traffic flows and
issue an advisory. However, there was no formal requirement for a specialist
to take action, and such action was a decision of the specialist. The CFCF
is not normally advised of cumulative holding times of airplanes as they
proceeded toward their destination airports.
A specialist at the CFCF monitors the effectiveness of a program by

comparing the number of airplanes that land during a particular hour with the
acceptance rate at which the program was set. The specialist calls the tower
at the airport where a program is in effect, and the tower provides him with
the number of departure airplanes for the previous hour.
A review of the CFCF traffic management program and associated

data for JFK on January 25, 1990, revealed that airplanes were holding for
as long as 95 minutes while waiting to land at JFK. This value is the total
holding time for a single holding fix and would not have included the time
at previous holding fixes.
JFK's Ground Delay Program
At 0630, on January 25, 1990, the CFCF specialist and the NY TRACON
specialist (N90) discussed the weather forecast for the New York area. The
discussion focused on how the forecast winds and weather conditions could
affect arriving airplanes at JFK and other New York airports during the
afternoon and evening. The specialists scheduled another discussion after
154
meteorologists at the affected ATC facilities had an opportunity to review

the weather situation.
At 0633, N90 advised Boston Center that JFK had just become a
single landing runway and that the NY TRACON specialist would need 30 miles
in-trail for traffic arriving at JFK via the LOVES fix. N90 advised Boston
that the restriction would be necessary until 0800.
At 0644, JFK tower informed the CFCF that it had changed runways
because of rain and fog and that it was now using runway 22 left for landings
and runway 22 right for departures.
At 0701, N90 advised the CFCF that "we got a lot of problems
already." Because of the surface wind, JFK had to begin ILS approaches to
runway 22 left. Then, LaGuardia Airport (LGA) had to conduct ILS approaches
to runway 13 for landing traffic and to use runway 4 for departure traffic.
This action was taken to prevent airplanes from conflicting with each other
while on approach to or departure from JFK or LGA. Also, arrivals to Newark
Airport (EWR) had to use the ILS to runway 4. In addition, restrictions were
placed on the number of arrivals per hour at Teterboro Airport (TEB), New
Jersey, because of the takeoff and landing configurations at EWR, LGA, and
JFK.
At 0746, a telephone conference was held between N90 and the CFCF.
The need for a JFK ground delay program was discussed. N90 advised the CFCF
that he believed JFK might have to change to ILS runway 13 left arrivals
because of the strong southeast winds that were forecast. N90 relayed the
same information to JFK, LGA, EWR, and TEB regarding active runways and
expected departure delays. Concerning what the arrival rate should be, based
upon the configuration of landing runway 13 left at JFK, N90 noted that they
"may only be able to do 28, that's a reality today, it's one of those
unfortunate days."
The CFCF specialist asked, "you don't think you can do 30 of 32?"
N90 responded, "I doubt it, though we could probably run a program around 30,
though."
N90 informed the CFCF that the engineered performance standards

(EPS) reflected an arrival rate for runway 13 left of 26 per hour. N909 also
informed the CFCF that the EPS does not take into account the additional
separation required for heavy jets. The CFCF informed N90 that in addition
to the JFK program there were seven programs in effect for other airports
and that a Boston program would also be implemented. The CFCF specialist
stated that the number of programs implemented could help the situation and
added that because of snowfall in Chicago, United Airlines would be reducing
its traffic for that area. The conversation was terminated with the
understanding that CFCF would compute the program and discuss it with N90
before implementing it.
The daily briefing for the major ATC facilities and users began at
0816. It consisted of forecast weather conditions and how those weather
conditions would affect the major airports throughout the day. The CFCF
1
155
specialist conducting the briefing advised that JFK would probably use the
ILS approach to runway 13 left because of forecast winds out of the south.
He also stated that a ground delay program would be implemented for JFK and
that it would begin at 1400. N90 stated the problems that would be
encountered if JFK were forced to change to ILS runway 13 left arrivals, and
especially how such a change would affect the rest of the New York
Metropolitan Area airports. When the briefing was given, JFK was operating
on runway 22 left. It was stated in the briefing that sporadic airborne
holding was already taking place in PHL, BWI, LGA, and EWR. The briefing
was concluded at 0835.
At 0839, Boston Center (ZBW) informed the CFCF that the Moncton
(New Brunswick) and Gander (Newfoundland) Centers had advised that the
overseas traffic would arrive between 1430 and 1600. ZBW stated that there
were 55 arrivals and that they appeared to be on schedule.
At 0855, the CFCF informed N90 that a JFK program had been
established for an arrival rate of 33 airplanes per hour. The CFCF stated
that the maximum ground delay would be 133 minutes, with an average of
84 minutes. He also said that "figuring in the disruption with the rest of
the system and one or two guys quitting, I feel that's a fair ground delay.
If I go to a 32 rate, it goes to 150; if I go to a 30 rate, it puts it up to
about 190 minutes maximum. I think that's in the ball park, but I want your
blessings also. N90 asked if the CFCF would wait 10 or 15 minutes, because
he wanted to check with someone else. N90 then said, "33 an hour sounds..."
The CFCF responded, "Well you are not going to get that, I really can't put
3-hour ground delays out." N90 stated, "No, no, I, I agree." N90 then
stated, "Well, why don't you go with it." The CFCF advised that the program
would run from 1400 until 2159. At 0909, the CFCF advised all domestic
ARTCCs that the JFK program was being transmitted.
At 1010, N90 called the CFCF to express concerns about the JFK
program and to inform the CFCF that he intended to implement "some very heavy
restriction," despite the ground delay program. The CFCF advised, "do
whatever you got to do:.. as worst scenario we are going to be on the ILS
thirteen...and at best, I think we're looking at 22s with a single runway,
anyway." At 1019, New York Center (ZNY) began implementing in-trail
restrictions with adjacent ARTCCs for JFK arrivals.
At 1102, ZBW called the CFCF to ask whether it could reduce the
in-trail restrictions requested by N90 for traffic landing at JFK. ZBW
stated that the 20 miles in-trail restriction inbound to JFK would be
difficult to accomplish since the were 50 airplanes coming and "the ground
delay program does nothing for this European traffic." At 1607, the CFCF
called N90 and explained that ZBW had requested a reduction in the 20 miles
in-trail restriction during the time that the overseas traffic was arriving.
To accomplish this reduction ZBW had suggested that additional restrictions
be placed on ZNY and Washington Center (ZDC). N90 stated that he did not
have room for these restrictions and that he was expecting the wind to begin
gusting in the next hour. N90 suggested that they discuss the problem with
ZBW, ZDC, and JFK to arrive at a reasonable solution. N90 also stated, “I
have a worst-case scenario operation."
156
At 1100, a telephone conference was held involving N90, ZBW and

JFK. CFCF asked ZNY if they would be able to accept additional in-trail
restrictions from 1400 until 1530. ZNY stated " . ..if that's the way it has
to be, that's the way it has to be." ZNY advised that if they were required
to implement 30 miles in-trail, they would go into an airborne hold. The
CFCF stated that he realized that a hold would be necessary but noted that
"the point is to put the least number of airplanes in the hold at the
appropriate time during the overseas rush. Boston has a heavy volume of
traffic. I would just like to move the restrictions around from one point to
the other during the least heaviest period of traffic."
N90 stated that he would be "real lucky" on an ILS to runway 13

left to be able to "do 25 arrivals an hour." ZBW stated that he had 55
arrivals coming in a 2 l/2 hour period, and said "what's airborne from us is
going to fill up your final for 2 l/2 hours if you look at it that way." N90
then stated, "Yea, see central, that's the unfortunate reality of the
operation tonight. If you want us to work the internationals, we'll do that
but you're going to have to understand that, ah, the only, the only
reasonable option is to give us only a few arrivals from everywhere else,
possibly a ground stop."
The discussion also centered on whether to reduce the in-trail

restriction for ZBW to 15 miles. The JFK sector supervisor at N90 then
stated, "even with the 20 . . . I just don't want anybody to be surprised if
we're going to be in a hold." N90 stated, "there's just nothing I can do
about it . ..33 like we ran is really unrealistic. Twenty-five is more what we
can run and that's if everything goes well . ..if we're shooting at 33 I
guarantee we'll be holding by 33."
After further discussion, it was determined that the solution would

be for a good estimate of how the traffic was moving at the beginning of the
"push." Such a push would involve using in-trail restrictions already
implemented and to implement a ground stop for the first 90 minutes for the
first tier ARTCCs and for the internal departures of N90, ZNY, and ZBW. All
facilities agreed that this method would probably be the best one for
preventing an airborne hold. The conference terminated at 1120.
At 1227:22, ZBW contacted the CFCF to discuss the JFK situation.

The facility informed the CFCF that Canada had notified them that there were
"at least 60 planes coming in that'11 be coming in over ERICK." He informed
the CFCF that if ZBW were to get "shut off and have to go into a hold, all
our alternate airports here are below minimums or at minimums." He stated
that he would like to have a backup plan and inquired about the possibility
of bringing some of the traffic over CAMRN (the ZNY arrival fix for JFK).
ZNY told ZBW that the best he could offer would be for ZBW to call on an
airplane by airplane basis and to determine if they could allow the reroute
over CAMRN. ZNY explained that he was anticipating problems over CAMRN as
well and that he already had large in-trail restrictions imposed on ZDC for
the CAMRN traffic.
At 1301, ZBW again asked ZNY about the possibility of bringing some
of the overseas arrivals into ZNY airspace. ZNY stated that he could not
157
approve the request. ZNY informed ZBW that he was aware of two
long-distance flights that would arrive through ZBW airspace via the Kingston
arrival. ZNY advised ZBW, "Okay when they come in the picture just give us a
heads up and we'll see what we can do for you." ZNY then asked the CFCF,
"who is taking care of the Kennedy stuff tonight"? The CFCF named the
specialist who was responsible, stating, "give him a message, I hope his
program is strong enough because I got bad vibes." ZBW then stated, "you can
put Boston on record for that too."
At 1345, N90 called the CFCF to inform him that the CFCF's aircraft
situation display (ASD) was not operating, and he asked if this ASD was the
only one that was inoperative. The CFCF informed N90 that all ASDs were
down.
At 1525, an unrecorded call was made to the CFCF advising, "I need
to speak to New York Center; I'm in a.hold for Kennedy over Kingston." The
CFCF responded that ZNY was on another line, but "looking at the ASD I
wouldn't think it's too bad because he's got about five of them out there
west side going to LENDY, looks like one of them is spinning and there is
only three of four coming from the south so I wouldn't think it's too bad."
The caller stated that he had two holding for JFK but that if he did not get
an update soon he would have to take them to ERICK, contrary to his wishes.
At 1547, N90 informed the CFCF that runway 22 right at JFK had
insufficient visibility for approaches and that there had been three or four
missed approaches on runway 22 left. He also stated that he had more than 12
airplanes on vectors, but "virtually we have no arrivals."
At 1601, the CFCF asked ZNY if he wanted to ground stop Kennedy's

arrivals. ZNY responded, "not yet." At 1604, the CFCF asked ZBW if he
wanted to stop his "internals" (airplanes departing from within ZBW
airspace) or "anything" for Kennedy. ZBW responded, "I already did." At
1604, the CFCF informed ZDC that airplanes were making missed approaches on
runway 22 left and that 22 right was below minimums at JFK. ZDC wanted to
know the number of airplanes enroute to JFK through ZDC airspace. The
transcript reveals approximately eight airplanes enroute to JFK that were
either in ZDC airspace or could be expected to enter ZDC airspace. ZDC
stated, "If that's all . ..we'll go ahead and not do anything for now."
At 1621, ZOB (Cleveland ARTCC) informed the CFCF that they were
holding airplanes for JFK and it was their understanding that every other
airplane was making a missed approach. At 1623, the CFCF called ZOB back and
suggested that they implement a ground stop for traffic landing at JFK,
"going back to Minney [Minneapolis ARTCC/ZMP] Chicago [ARTCC/ZAU] and INDY
[Indianapolis ARTCC/ZID]." ZOB agreed. The CFCF informed ZMP, ZAU, ZID, and
ZKC (Kansas City ARTCC) to ground stop departures to JFK until 1730. The
transcript reveals that between ZOB and ZDC approximately 17 airplanes were
discussed as being enroute to JFK. About 12 or 13 airplanes were in N90
airspace and, according to information from ZNY, 10 airplanes ,were holding at
CAMRN and LENDY intersections, and AVP (over Wilkes-Barre, Pennsylvania),
between 1600 and 1630. Thus, approximately 39 airplanes were in the airborne
158
inventory, not including traffic from ZBW or airborne traffic beyond these
ARTCCs.
The CFCF specialist's worksheet included the following entries:
2020 [1520 eastern standard time (EST)] - 22R BLO 22L, 4

misses, may have to change to RW13 ILS.
2102 [1602 EST] - JFK missing on 22L - VSBY LO. ACFT

holding, will try ILS 13, however, RVR [runway visual range]
is only about 100' more.
2102 - ZBW ground stopped internals to JFK. Req if ZNY want

grnd stop - they advise no.
The N90 TMU log includes the following entry at 1602 EST:
JFK: VSBY/RVR decrsng; numerous missed apches; CF2 will

ground stop lst/2nd tier centers, landing JFK....
The ZDC TMU log contains the following entry at 2125 [1625
eastern standard time]:
In Hold for JFK - 9 flights in ZDC. Rx.
At 1625, ZNY informed the CFCF that arrival delays to JFK had
exceeded 15 minutes at 1611 and would exceed 30 minutes at 1626.
At 1627, ZDC called ZNY to ask, "how long we're going to be on

hold for the Kennedys?" ZNY responded, "they just started running them I
think they're taking them 20 [miles] in-trail. As soon as we clean them out
we'll start taking them from you." ZNY also explained that the weather was
affecting the approach, "It's blowing off the water...it goes down and it
comes up it goes down and it comes up."
At 1631, N90 informed the CFCF that airplanes were again making
approaches to runway 22 left. He also informed the CFCF that the visibility
was l/4 mile and that the RVR was 2,000 feet.
At 1640, the CFCF advised N90 of an aircraft inbound to JFK that

needed a "priority" landing because of a sick passenger. At 1643, ZNY asked
ZOB if the pilot had requested priority handling because of the holding for
JFK. ZNY stated, "I want to make sure that if we are going to run him
priority that he is declaring a priority handling." ZOB confirmed that the
pilot was indeed requesting priority because of the sick passenger.
At 1647, the CFCF initiated a call to JFK to request the number of

arrivals and departures for the 1400 and 1500 hours. JFK informed the CFCF
that from 1400 to 1459 there were 17 arrivals and 10 departures at JFK.
From 1500 to 1559, there were 31 arrivals and 1 departure at,JFK.
159
At 1651, ZNY informed the CFCF that JFK arrival delays had
decreased to fewer than 30 minutes at 1626 and to fewer than 15 minutes at
1635.
At 1659, N90 informed the CFCF that the RVR at JFK was "just over
three grand [3,000 feet]," and advised that "as long as it stays where it is
we're going to be fine." At 1700, the CFCF called ZNY to determine their
holding situation. ZNY advised that they were taking traffic destined for
JFK from ZOB. Because they had room for them. ZOB informed asked CFCF not
to cancel the ground stop because he had eight airplanes remaining in his
holding stack. The CFCF replied, "Okay you let me know when."
At 1705, ZOB told the CFCF, “I guess they are slowly surely taking
these Kennedy guys. Go ahead and let them go." ZOB asked the CFCF to
monitor the situation, and the CFCF stated that he would do so as soon as the
ASD came back on line. The CFCF contacted ZMP, ZAU, and ZKC at 1705 and
instructed them to cancel the ground stop for JFK.
At 1706, the following entry was recorded in the N90 log, "JFK:
hold CAMRN. We'll favor LENDY due to demand/ASD." The 1708 ZNY log entry
states, "Holding CAMRN."
At 1710, ZBW informed ZNY that there was an airplane holding at

Kingston that had been holding for nearly an hour. ZBW inquired whether ZNY
could get the airplane started toward JFK. ZNY replied, "I'll see if I can
get him through for you." The CFCF log also noted that the ASD computer was
back in service at 1710.
At 1733, N90 provided an update to the CFCF regarding the New York
Metropolitan airports. Regarding JFK, he stated, "Kennedy has been
fluctuating but they have been mostly above minimums so they're running
okay." At 1739, the CFCF was informed that the arrival delays for JFK
exceeded 15 minutes at 1724 and exceeded 30 minutes at 1739.
The N90 log entry for 1745 states, "JFK: based on ASD/demand,
we'll hold LENDY and accept CAMRN TFC." An entry at 1751 stated that CAMRN
traffic would be accepted 10 miles in-trail and LENDY traffic would continue
to hold. AT 1753, N90 informed the CFCF regarding CAMRN, “I see Washington's
holding and New York down to the southeast...whatever we can accept we're
accepting."
At 1803, ZNY requested a ground stop for JFK traffic arriving from
the south. He informed the CFCF, "we're looking at extensive delays until
they get that CAMRN area and Washington Center cleared up." A discussion was
held concerning the number of airplanes headed toward ZDC airspace enroute
to JFK. The CFCF asked ZDC if airplanes were being held at Raleigh, North
Carolina. ZDC responded, “I don't know if they are holding down there yet,
they might still be driving them on up if we only got four up at the north
side they're going to drive them up, E area can hold a bunch more."
ZNY told ZDC that it appeared that ZDC traffic would have to hold a
minimum of 45 minutes. The ZDC log has the following entry at 1807, "Ground
160
stop JFK due to weather." The log entry for ZDC for 1810 is, "observing
numerous A/C diverting due to long holding delays." A ZNY log entry at 1836
stated, "holding CAMRN/LENDY due vol."
Among other entries regarding holding at CAMRN, ERICK and LENDY

fixes, the log at 1837 for N90 shows "JFK: hold CAMRN and ERICK, vol." and
at 1841, "JFK: radar CAMRN, 10 MIT based on vol/ASD."
The ZDC log states at 1915 that the "in house" ground stop for JFK
was cancelled. At 1935, the N90 log reflected a radar operation (traffic
being handed off to another controller via automation and no verbal
coordination necessary) for traffic at CAMRN.
At 2007, JFK reported to the CFCF and N90 that departure delays had
exceeded 30 minutes due to "IFR weather missed approaches arrivals crossing
the departure runway and aircraft timing out at the No. 1 position."
At 2035, a shift change occurred and a different specialist from

CFCF took over monitoring the JFK program. He called JFK to inquire about
the weather conditions. JFK responded, “It’s pretty bad, we got all sorts of
windshears and missed approaches due to not seeing the runway...we're ILS
two two left trying to depart two two right . ..the wind's starting to pick up
so there is no chance of us making any runway change...out of the last hour I
think 20 percent of the guys attempted approaches went on to miss." Traffic
count information provided by JFK indicates that seven airplanes executed
missed approaches between 1900 and 1959.
At 2036, the CFCF called N90 to inquire about the holding

situation. N90 stated that "we're still working out of a hold." CAMRN was
still holding, "but they've only got a few that I can see real close." N90
also advised that there was "a front coming through it's about 15 miles west
of Newark right now."
At 2038, the CFCF was advised that arrival delays had exceeded
45 minutes at JFK at 1948 and had dropped below 45 minutes at 1950.
At 2040, the CFCF and N90 had a discussion about the approaching
weather and how some departures from the New York Metropolitan airports would
be held on the ground and some would be rerouted around the weather. At
2040, the CFCF specialist had entered on his work sheet, "JFK tower advises
20 percent arvls have m.a. [missed approaches] in past hour, due to windshear
G-stop/0300Z [Ground stop at 2200 EST]. A ground stop, however, was not
implemented until 2057, when the CFCF conferred with ZNY and ZDC. At 2057,
the list of airplanes filed for JFK indicated that five should still have
been held on the ground. At 2059, a ground stop for traffic arriving at JFK
was implemented for ZNY, ZDC, ZOB, ZID, ZTL (Atlanta ARTCC), and ZJX
(Jacksonville ARTCC). An advisory was sent by the CFCF at 2059 indicating
that first tier centers would ground stop traffic to JFK until 2200.
161
At 2047, the approximate time that AVA052 was cleared out of the
CAMRN holding pattern into N90 airspace, an entry in the N90 log states,
"JFK: holding CAMRN; favoring 4 acft holding at LENDY that are being
impacted by WX [weather]."
At 2125, ZOB asked ZNY when they (New York Center) might be able to
take the airplanes holding in ZOB airspace, destined for JFK. ZOB stated
that some of the airplanes had "to make a decision now whether they got to
divert or not." ZNY advised ZOB that it would be "anywhere from 45 minutes
to 60 more minutes at the latest." ZNY also advised that they were still
"holding a lot" and that a storm would probably hit JFK "in the next half
hour."
At 2138, ZID called CFCF to discuss the ground stop for JFK and
other New York airports. The CFCF advised that the ground stop for JFK may
extend beyond 2200, "because they're doing a lot of holding."
At 2143, N90 informed the CFCF that radar contact had been lost
with an Avianca flight and that traffic in and out of JFK had been stopped.
An entry in the N90 log at 2135 states, "JFK: holding all fixes...emergency
in progress." An entry in the CFCF log at 2146 states, "JFK...all arrivals
stopped due to assumed crash of Avianca Flt 52 approx 15 miles ne of JFK."
The CFCF log had the following entry at 2200, "JFK resuming
approaches due to confirmed crash site per N90." At 2206, the N90 log entry
states, "TMU, resumed JFK arrvls, 15 wit [miles-in-trail]."
At 2204, the CFCF conference called with ZNY, ZDC, ZBW and ZID to
determine the number of airborne airplanes still holding for JFK.
Approximately 20 to 25 airplanes were still in holding patterns awaiting to
land at JFK.
162
APPENDIX D
ATC TRANSCRIPT
This transcription covers the time period from January 26, 1990
UTC d a t e , 0104 t o January 26, 1990 UTC d a t e , 0153 UTC.
Aaencies Making Transmissions Abbreviation

Nev York ARTCC, Position H67 H67
Nev York ARTCC, Position R67 R67
New York TRACON, JFK Arrival N90
Washington ARTCC, Sector 51 ZDC51
Transvorld Airlines Flt 33 TWA33

Aeronaves de Mexico S.A. Flt 406 AMX406
Avianca Flt 052 AVA052
Air France AFRO26
Westvind Jet N422AW N422AW
Saudi Arabian Airlines Flt 024 SVM024
Pan American World Airvays Flt 224 PAA
Pan American World Airvays Flt 1812 PAA
I HEREBY CERTIFY that the folloving is a true transcription of

the recorded conversations pertaining to the subject aircraft
accident:
Q u a l i t y A s s u r a n c e Sbecialist
(0104)
0105:12 TWA33 A h T W A t h i r t y t h r e e w i t h y o u outa flight

level tvo zero seven for one niner zero.
163
0105:16 R67 TWA thirty three heavy Nev York Center

roger holding instructions at CAMRN vhen
y o u ’r e r e a d y .
0105: 21 TWA3 3 Roger go ahead.
0105:23 R67 TWA thirty four cleared to CAMRN hold at’

CAMRN as published, left turns, ten mile
legs, m a i n t a i n f l i g h t l e v e l o n e n i n e
zero, expect further clearance at zero
one tvo five.
0105:35 TWA33 Ok ve’ ll steer zero one tvo five and ah

hold at CAMRN as published ah ten mile
legs ah flight level one niner zero left
turns could you make it twenty mile
legs?
0105:45 R67 N e g a t i v e s i r a h t w e n t y vi11 s p i l l o u t a h

everyone else is diverting I need you
ten.
0105:50 TWA33 Roger ah understand ten mile legs ah TWA

ah (unintelligible).
0105:54 R67 Thank you.
(0106)
(0107)
0108:42 R67 TWA thirty three descend and maintain

one three thousand Kennedy altimeter two
nine seven one.
0108:48 TWA3 3 Down to one three thousand twenty nine

seventy one ah TWA thirty three.
0109:03 TWA33 And ah TWA thirty three leaving one nine

oh.
0109:05 R67 TWA thirty three roger.
0109:43 TWA33 And ah confirm the altimeter twenty nine

seventy one.
164
01,09:46 R67 Two nine seven one.
0109:49 AVAO52 New York Kennedy Avianca zero five t&

heavy good evening ahh leveling at one
niner zero.
0109:54 R67 Avianca zero five two heavy Nev York

Center good evening 1’11 have holding
instructions at CAMRN when you’re ready.
0109: 59 AVA52 Alright.
0110:01 R67 Avianca zero five two heavy cleared to

CAMRN CAMRN*s your clearance limit hold
as published, left turns, ten mile legs,
and ah, m a i n t a i n f l i g h t l e v e l o n e n i n e r
zero expect further clearance at zero
one three zero.
0110:20 AVA502 Avianca zero five two heavy cleared to

CAMRN and ah we’ ll hold as published ah
left turns ahh I missed ah how much
legs, how much ah nautical mile.
0110:33 R67 One zero, ten mile legs.
0110:35 AVA052 Ten mile legs maintaining one niner zero

and expect further clearance zero one
three zero.
0111: 11 PAA Ah New York Clipper two tvo four.
0111: 33 PAA Ah New York Clipper tvo two four.
0111: 36 R67 Clipper tvo twenty four go ahead.
0111:38 PAA Yes sir. How’s t h a t f i f t e e n t i m e lookin

for us.
0111: 41 R67 Urn I’m g o n n a g i v e h i m a c a l l a n y s e c o n d

nov I’ ll let you know.
0111:44 PAA Ok thank you.

e
165
(0112)
0113: 56 TWA33 And TWA thirty three entering the hold

at CAMRN.
0113:59 R67 TWA thirty three roqer.
0114 :‘05 R67 Clipper two twenty four the EFC at

fifteen not looking too good however
before I give you a new one just hold
off a minute or tvo sir approach control
gonna call me back give me an idea
vhat’ s gofn on.
0114:14 PAA Ok ah two two ah four thank you sir.
0115: 43 R67 Avianca zero five two descend and

maintain one four thousand Kennedy
altimeter tvo nine seven one.
0115: 49 AVA052 Descend and maintain one four thousand

two niner seven one Avianca zero five
two heavy.
0116: 44 R67 Clipper tvo twenty four they said about

another ten minutes sir expect further
clearance at ah zero one three zero.
0116:SO PAA Ah ah roger ahhh about another fifteen

minutes then zero one ah three zero
that’s the limit for us ah well have to
divert on it.
0116: 59 R67 Ok keep me advised sir and I’ll let you

know if ah anything changes.
0117: 02 PAA Ok fine thank you very much.
0117:04 R67 Your welcome.
0117:06 R67 Air France zero tvo six expect further

clearance zero one three three.
I
166
01.17 :lO AFRO26 Zero one three three further ah

expectations Air France zero two six
heavy.
0117:16 R67 TWA thirty three expect further

clearance zero one three six.
0117:21 TWA33 Zero one three six.
(unintelligible).
0117:27 R67 Say again.
0117:30 TWA33 TWA thirty three expect further

clearance zero one three six.
0117:33 R67 TWA thirty three roger.
0117:36 R67 Avianca zero five tvo ah

(unintelligible) expect further
clearance zero one three nine.
0117: 41 AVA052 Ok zero one three nine ah

(unintelligible) Avianca zero five two
heavy.
0118:04 TWA33 And TWA thirty three requesting ah

holding speed at about two hundred
thirty knots or less is still valid.
0118:09 R67 Ok just ah no more than ten mile legs

sir.
0118:12 TWA33 Affirmative.
(0119)
0120:30 PAA Ah Nev York the Clipper tvo two four.
0120: 33 R67 Clipper two two four good news ah ve

have a turn into Kennedy for you now.
I I
167
0120:38 PAA R o g e r “ah’@ thank you very much ah We’re

ready whenever you are.
0120: 41 R67 Clipper two twenty four heavy cleared to

the Kennedy Airport via left turn
heading zero four zero maintain speed
two one zero ah maintain eleven
thousand.
012O:Sl PAA Roger left turn ah heading of zero four

zero to Kennedy maintain two ten on the
speed maintain one one thousand.
0120:58 R67 Clipper two twenty four heavy contact

New York Approach one tvo seven point
four good night.
0121: 03 PAA Roger one twenty seven four, good night

sir and thank you for all your help.
0121:12 R67 Air France zero tvo six heavy say

heading.
0121: 15 AFRO26 Turning ah left ah zero two six heavy.
0121: 28 AFRO26 We’re turning back to CAMRN Air France

zero two six heavy.
0121: 32 R67 Air France zero two six heavy ah fly

heading of two three zero, two three
zero heading vectors for Kennedy.
0121: 38 AFRO26 L e f t t u r n or r i g h t t u r n .
0121: 43 R67 Air France zero two six fly heading one
five zero one fifty heading vectors for
Kennedy.
0121: 47 AFRO26 Heading one five zero to Kennedy Air

France zero tvo six heavy.
I I
I
168
0121:51 R67 Roger.
0122:27 R67 Air France, zero tvo six heavy cleared

to the Kennedy Airport via.present
heading vectors for Kennedy descend and
maintain one one thousand
(unintelligible) speed two one zero.
0122:36 AFRO26 Down one one thousand speed tvo one zero
ah Air France zero two six heavy.
0122:41 R67 Roger.
0123:ll R67 A,ir F r a n c e z e r o t w o s i x h e a v y t u r n l e f t

heading three four zero.
0123:lS AFRO26 Left heading three four zero Air France

.zero t w o s i x h e a v y .
0123:32 R67 TWA thirty three heavy cleared the

Kennedy Airport via heading tvo three
five v e c t o r s f o r K e n n e d y m a i n t a i n o n e
three thousand.
0123:39 TWA33 Ok cleared to Kennedy ah heading two

three five ah maintain one three
thousand TWA ah thirty three.
0123:46 R67 Roger.
(0124)
0125:OS R67 Air France zero two six heavy fly

heading zero three zero.
0125::09 AFRO26 Heading zero three zero Air France zero

two six heavy
0125:12 R67 Air France zero two six heavy contact

New York Approach one two seven point
four.
169
0125:16 AFRO26 One tvo seven four Good bye.
0125:18 R67 Good night.
0125:27 R67 TWA thirty three heavy descend and

maintain one one thousand.
0125:31 TWA33 TWA33 thirty three heavy dovn to one one

thousand leaving on three thousand.
0125:47 AFRO26 Ah confirm frequency for Air France ah

z e r o t v o s i x h e a v y I'm s o r r y .
0125:Sl R67 Air France zero tvo six heavy one tvo
seven point four.
01225:54 AFRO26 Roger thank you very much.
0125:57 R67 Good night.
0126:43 R67 TWA thirty three heavy turn left heading

z e r o t h r e e zero.
0126:47 TWA33 Left heading zero three zero TWA thirty

three heavy.
0126:Sl R67 And TWA thirty three heavy maintain

speed of ah tvo one zero..
0126:55 TWA33 Tvo hundred and ten knots TWA thirty

three heavy.
0126:58 R67 Roger.
0127:47 R67 TWA thirty three heavy ah, fly heading

zero four zero.
0127:49 TWA33 Ok zero four zero TWA thirty three

heavy.
170
01.27:52 R67 Avianca zero five tvo heavy cleared to

the Kennedy Airport via fly heading two
t h r e e zero d e s c e n d a n d m a i n t a i n , o n e - , - -
one tvo thousand.
0128:Ol AVA052 Descend and maintain one two thousand on

a heading tvo three zero Avianca zero
five tvo heavy.
0128:07 R67 Avianca zero five tvo heavy roger.
0128: 39 R67 TWA thirty three heavy contact New York

Approach one tvo seven point four good
night.
0128: 44 TWA33 Twenty seven four TWA ah thirty three

heavy so long.
0129:30 R67 Avianca zero five tvo heavy traffic

e l e v e n o ’c l o c k a n d a h s i x m i l e s o p p o s i t e
direction at one one thousand maintain
one two thousand.
0129:39 AVA052 A n d ve’re l o o k i n g f o r i t , a n d we’ ll
maintain one tvo thousand Avianca zero
five tvo heavy.
0129:43 R67 Roger.
0129:45 PAA New York Center Clipper eighteen tvelve

heavy at ah one seven thousand.
0129:49 R67 Clipper eighteen tvelve heavy Nev York

C e n t e r r o g e r K e n n e d y a l t i m e t e r t v o niner
seven one.
0129:55 PAA Eighteen tvelve heavy tvo nine seven

one.
(0130)
0131:37 R67 Avianca zero five tvo heavy turn left

heading zero four zero descend and
171
0131: 44 AVA052 Left heading zero four zero Avianca zero

five tvo heavy descend and maintain one
one thousand.
0139:49 R67 A v i a n c a z e r o f i v e t v o h e a v y roger

maintain speed tvo one zero.
0131: 53 AVA052 Maintain tvo one zero knots Avianca zero

five tvo heavy.
(0132)
(0133)
0134:18 R67 Clipper eighty one tvelve heavy descend

and maintain one tvo thousand.
0134:22 PAA That Clipper eighteen tvelve to one tvo

thousand.
0134:26 R67 I’m s o r r y C l i p p e r e i g h t e e n t v e l v e

descend and maintain one two thousand.
0134:29 PAA Eighteen tvelve heavy out of one seven

for one tvo thousand.
0134:32 R67 Avianca zero five tvo heavy ah turn left

go left three sixty left three sixty for
Avianca zero five tvo.
0134:41 AVA052 Turn left three sixty for Avianca zero

five tvo heavy.
0134:43 R67 Roger
0134: 46 R67 Clipper eighty one tvelve heavy cleared

t o t h e CAHRN intersection.hold s o u t h v e s t
as published maintain one tvo thousand
expect further clearance time zero one
four zero.
172
0135:05 R67 Clipper eighteen tvelve heavy cleared to

the CAMRN intersection maintain one tvo
thousand hold southvest as published
e x p e c t f u r t h e r c l e a r a n c e zero o n e f o u r
zero.
0135:14 PAA CAMRN ah hold as published'ah zero one

four zero at tvelve thousand Clipper
eighteen tvelve heavy.
0135:20 R67 Roger.
0135:24 N442AW Evening New York vestvind four two two

Alfa Whiskey one niner zero.
0135:28 R67 Four four two Alfa Whiskey New York

Center roger.
0135:35 R67 ’ Avianca zero five tvo heavy ah RVR at

Kennedy is ah tventy four hundred feet
can you accept an approach?
0135:42 AVA052 T h a t ’s a f f i r m a t i v e s i r .
0135:43 R67 Avianca zero five two roger.
0135:46 R67 Clipper eighteen twelve heavy what type

of RVR do you, do you, do you need to
thirteen left.
0135:52 PAA T h i r t e e n l e f t a h we’ll l o o k i t u p , a n d
i t s p r o b a b l y , ah is that. a cat two
approach.
0135:58 R67 Ah stand by one we just vanna confirm

this thirteen left stand by one.
0136:03 PAA Ok, ah eighteen twelve is a cat three

aircraft.
0136~05 R67 Ok.
0136:SO R67 Avianca zero five tvo ah say your

heading at this time.
173
0136:54 AVAOSZ Ah ve*re p a s s i n g a h o n e f i v e z e r o .
0136:58 R67 Avianca zero five tvo continue to the'

left heading tvo three zero. vectors for
holding at CAMRN again.
0137:04 AVA052 Ok tvo three zero vectors for holding at

CAMRN .
0137: 07 PAA Nev York Clipper eighteen twelve.
0137: 10 R67 Clipper eighteen tvelve go.
0137: 12 PAA Sixteen hundred RVR for one three left.
0137:14 R67 C l i p p e r e i g h t e e n t v e l v e roger a h e x p e c t

further clearance time nov zero one five
z e r o I’m g o n n a t a l k t o K e n n e d y t h e y j u s t
put us back in a hold’.
0137:24 PAA Roger zero one five zero nov.
0137:28 R67 O k a n d i t s a h t v e n t y tvo’

s the runvay in
use at Kennedy nov.
0137:33 PAAl O k .
0137:35 R67 Westvind four tvo tvo Alfa Whiskey

cleared to the CAMRN intersection hold
southwest as published descend and
maintain one five thousand expect
f u r t h e r c l e a r a n c e t i m e zero o n e f i v e
five.
0137:48 N422AW CAMRN to hold southvest as published at

fifteen thousand zero one five five.
I
174
0137:54 R67 Four four tvo Alfa Whiskey I missed the

altitude (unintelligible) five thousand.
0137:57 N422AW Y e s s i r ve’

re l e a v i n g n i n e t e e n for
fifteen nov.
0138:OO R67 Thank you.
0138:53 AMX406 Nev York Center Air Mexico four zero six
maintaining flight level one niner zero.
0138:58 R67 Air Mexico four zero six heavy Nev York
Center roger cleared to the CAMRN
intersection hold southvest as published
maintain flight level one niner zero
e x p e c t f u r t h e r c l e a r a n c e t i m e zero tvo
zero zero.
0139:lO AMX406 Ah roger ah cleared to CAMRN

intersection ve’ll hold over CAMRN
intersection and expect further
clearance zero two zero zero.
0139:21 N422AW Hov about an altimeter for Alfa Whiskey

please.
0139:25 R67 Four four tvo Alfa Whiskey I believe you

a s k e d for t h e a l t i m e t e r t v o n i n e s e v e n
zero.
0139:27 N422AW Tventy nine seventy tvo Alfa Whiskey

thank you.
0139:30 R67 Air Mexico four oh six heavy confirm

assigned altitude flight level one nine
zero.
0139:34 AMX406 Affirmative one niner zero.

175
0139:Sl (UNK) Did you say they’re landing on tvo tvo

left nov.
0139:54 R67 T h a t ’s c o r r e c t .
0139:52 (UNK) Thank you.
0140:17 R67 Four four tvo Alfa Whiskey maintain one

four thousand.
0140:21 N422AW One four thousand and thats ah four tvo

tvo Alfa Whiskey.
0140:24 R67 Four four tvo Alfa Whiskey sorry about

that.
0140: 27 N422AW No sir four two tvo ALPHA Whiskey.
0140:30 R67 Four tvo two Alfa Whiskey all right let
me change your flight plan.
0140:33 N422AW OK thanks.
0140:35 PAA Ah Clipper ah eighteen twelve heavy

entering the hold at CAMRN descending to
one tvo thousand.
0140:43 R67 Clipper eighteen tvelve heavy roger.
0141:39 R67 Westvind tvo Alfa Whiskey maintain one

three thousand.
0141:42 N422AW One three thousand Alfa Whiskey.
014153 R67 Air Mexico four zero six heavy descend

and maintain one four thou&and Kennedy
a l t i m e t e r t v o nine seven zero.
176
0141:59 AMX406 Ah roger cleared to fourteen thousand

the altimeter tvo niner seven zero Air
Mexico four zero six.
0142:04 R67 Roger.
0143:20 R67 Liberty south DIXIE ninety three CAMRN

ninety three point out.
0143:24 N90 Go ahead.
0143:25 R67 I get ah aircraft north of ZIGGY by a

fev miles leaving fourteen descending in
the hold squavking ten fifty four.
0143:29 N90 Ok vhat kind of heading do you need

Continental six eighty three on.
0143:32 R67 I'm sorry this is the CAMRN

intersection.
0143:34 N90 Ah ok.
0143:35 R67 Alright.
0143:36 N90 Alright t h a t ' s a h s h o u l d b e a p p r o v e d .
0143:38 N90 What's h e d e s c e n d i n g t o ? What's h i s

heading?
0143:40 R67 He's d e s c e n d i n g t o t h i r t e e n he's ah

entering the hold at CAMRN.
0143:42 N90 Alright t h a n k s . ( i n i t i a l s )
0143:53 AVA052 Kennedy AVIANCA zero five tvo heavy.

177
0143:56 R67 Avianca zero five two heavy go ahead.
0143:59 AVA052.. Thank you sir you have ah .any estimates

for us.
0144:02 R67 Avianca zero five tvo heavy ah might be

able to get you in right nov stand by
one.
0144:06 AVA052 Thank you.
0144:09 R67 Avianca zero five tvo ah ve just got off

the line its ah indefinite hold at this
time Avianca zero five two turn left
heading zero nine zero join the Deer
Park tvo tventy one radial hold at CAMRN
0144:23 AVA052 Ok Avianca zero five tvo heavy turning

left zero nine zero to join ah two two
one Deer Park radial and holding CAMRN.
0144: 32 R67 Avianca zero five tvo roger.
0144:43 R67 Avianca zero five two heavy expect

further clearance time zero tvo zero
five.
0144:so AVA052 Zero two zero five ahhhh vell I think ve

n e e d p r i o r i t y ve’
re p a s s i n g
(unintelligible).
0144: 58. R67 Avianca zero five two heavy roger how
long can you hold and ah vhat is your
alternate
0145:03. AVA052 Ok stand by on that.
0145:06 R67 Clipper eighteen tvelve heavy expect

f u r t h e r c l e a r a n c e t i m e zero t v o t e n .
178
0145:ll PAA Eighteen tvelve heavy zero two ten.

(unintelligible) field closed there now
(unintelligible).
0145:16 R67 Ah they just had a fev aircraft try an

approach they all missed so ah there not
taking any traffic right now I guess
t h e y h a v e t o vait a l i t t l e b i t a h t r y i n g
t o t a l k t o ‘em o v e r t h e l a n d l i n e
they're really not ansvering the line
i t s h a r d , h a r d t o t a l k t o ‘em.
0145: 30 PAA Ok thank you.
0145: 37 R67 Four two tvo Alfa Whiskey expect further

clearance time zero tvo one five.
0145:43 N422AW Ah roger zero two one five four tvo tvo
Alfa Whiskey.
0145:47 R67 Air Mexico four oh six heavy expect

further clearance time zero tvo tvo
zero.
0145:52 AMX406 Ah roger zero tvo tvo zero for Air

M e x i c o f o u r zero s i x n o v r e a c h i n g
maintaining one four thousand.
0145:57 R67 Roger.
0145:59 AVA052 Kennedy Avianca zero five two heavy.
0146:Ol R67 Avianca zero five tvo heavy go ahead.
0146:03 AVA052 Y e s s i r a h vet11 b e a b l e t o h o l d a b o u t

five minutes thats all ve can do.
0146:08 R67 Avianca zero five tvo heavy roger vhat

is your alternate?
\
I
179
0146:13 AVA052 Ah ve said Boston but ah it is ah full

of traffic I think.
0146:20 R67 Avianca zero five tvo say again your

.. alternate airport.
0146:24 AVA052 I t v a s B o s t o n b u t v e v e c a n ’t d o i t n o v
v e , w e , don’ t, v e r u n o u t o f f u e l n o w .
0146:29 R67 Avianca zero five tvo ah just stand by.
0146:32 AVA052 Thank you.
0146:47 R67 Avianca zero five tvo heavy cleared to

the Kennedy Airport via heading zero
four zero maintain one one thousand
speed one eight zero.
0146:57 AVA052 Ok cleared to the Kennedy, zero four

zero on the heading, maintaining one one
thousand one eighty on the speed thank
you.
0147:04 R67 Avianca zero five tvo heavy contact Nev

York Approach one tvo seven point four.
0147:08 AVAO52 One tvo seven point four.
0148:59 R67 Clipper eighty one tvelve heavy descend

and maintain one one thousand.
0149:03 PAA For ah Clipper eighteen tvelve.
0149:os R67 G e e s o r r y a b o u t t h a t that’ s the fifth

t i m e I’ve s a i d t h a t C l i p p e r e i g h t e e n
tvelve descend and maintain one one
thousand.
0149:12 PAA Dovn to one one thousand Clipper

eighteen tvelve.
I
180
0149:39 R67 Clipper eighteen twelve heavy ah New

York Approach advises at least another
thirty minutes in the hold.
0149:45 PAA Clipper eighteen tvelve ah thank you.
0149:49 R67 Four tvo tvo Alfa Whiskey and Air Mexico
four oh six heavy at least another ah
half an hour to forty minutes in the
hold.
0149:56 AMX406 Ah roger Air Mexico four zero six.
0149:58 N422AW Alfa Whiskey roger.
015O:ll SVA024 Nev York Center Saudi zero tvo four

heavy good evening ah climbing to one
four thousand.
0150:18 R67 Saudi zero tvo four heavy Nev York

Center good evening cleared to the CAMRN
intersection hold southvest as published
maintain one four thousand and expect
further clearance time zero tvo four
zero.
0150:34 SVAO24 Roger direct to CAMRN hold

(unintelligible) expect, expect ah
approach zero zero tvo four zero.
0150:44 R67 Saudi zero tvo four heavy expect further

clearance zero tvo four zero maintain
one four thousand.
0150:49 SVA024 Expect further clearance zero tvo four

zero maintain one four thousand.
0150:55 R67 Roger.
0150:58 R67 Four tvo tvo Alfa Whiskey descend and

maintain one tvo thousand.
181
0151:02 N422AW Ah roger outta thirteen for one tvo

thousand four tvo tvo Alfa Whiskey.
0152:07 R67 Air Mexico four zero six heavy descend

and maintain one three thousand.
0152:12 AMX406 Ah roger Air Mexico four zero six heavy

l e a v i n g o n e f o u r f o r one t h r e e t h o u s a n d .
0152:44 R67 Saudi zero tvo four heavy say heading.
0152: 51 SVA024 Zero five zero and (unintelligible) zero

four one from Deer Park.
END OF TRANSCRIPT
182
This transcription covers the time period from January 26, 1990
UTC date, 0104 to January 26, 1990 UTC date, 0153 UTC.
Auencies Makinu Transmissions Abbreviation
New York ARTCC, Position H67 H67
Nev York ARTCC, Position R67 R67
New York ARTCC, Position H66 H66
Nev York TRACON, JFK Arrival N90
Unknown UNK
I HEREBY CERTIFY that the following is .3 true transcription of

accident:
Gerald S.
Quality Assurance Soecialist
0104:05 UNK MANTA eighty one.
0104:17 H67 Who you calling?
0104:18 UNK MANTA.

183
0104:19 H67 Oh uh hold on.
0105:45 H67 Sea Isle CAMRN ninety nine.
(0106)
(0107)
(0108)
(0109)
(0110)
0111:49 H67 Kennedy CAMRN six any updates.
0112:36 H67 Kennedy CAMRN on the six any updates.
0112:39 N90 I'll try to ge t an update for you I'll

call you back.
0112:42 H67 Alright N F.
0112:43 N90 PB
0116:24 N90 CAMRN Kennedy six.
0116:26 H67 Yeah.
0116:27 N90 They tell me ten more minutes.
0116:28 H67 They say ten more minutes.
0116:30 N90 Ten more its alvays ten more

(unintelligible).
0116:31 H67 Alright yeah just keep me advised ok.
0116:33 N90 Ha Ha.

184
0116:34 H67 Alright.
0116:35 N90 Alright thank you.
0116:36 H67 N F.
(0117)
(0118)
0119: 49 N90 CAMRN Kennedy six line.
0119:Sl H67 Hello.
0119:52 N90 Lets start ah taking some airplanes

here.
0119:55 H67 Oh right what do you need.
0119:56 N90 (Unintelligible) in trail.
0119:57 H67 How much?
0119 : 59 N90 He says twenty in trail.
012O:Ol H67 Twenty in trail and two ten on the

speed.
0120:02 N90 That*11 work.
0120:03 H67 Alright here we go first ones Clipper

two twenty four N F.
0120:04 N90 RH.
0120:06 H67 Yeah will do.
0120:07 N90 Ah let me ask.
0120:09 H67 Ah ha alright.

185
0121:52 H67 Yep six six seven point out computer

zero two four like to put on a one fifty
heading and then back into CAMRN ,
descending to one one thousand.
0121:59 H66 Ah one fifty heading you said.
0122:Ol H67 Yes.
0122:02 H66 Ah.
0122:03 H67 For a while and then back into CAMRN

like about a ten.
0122:OS H66 Ok yeah that's approved.
0122:06 H67 Alright N F.
(0123)
(0124)
(0125)
(0126)
(01271
0128:OO H67 CASINO CAMRN eighty one line.
0128:02 w51 CASINO.
0128:04 H67 Urn whose first in ah your holding there.
0128:07 w51 Number one would be ah Clipper eighteen

twelve at seventeen.
0128:12 H67 Clipper eighteen twelve ah.
0128:13 w51 Want me to flash him (unintelligible).

I
186
0128:14 H67 Yeah, why don't, actually, yeah why

don't YOU flash him, urn tell him ah slow
as possible Clipper-eighteen twelve is
radar contact and I'll call you on the
others.
0128:25 w51 Alright.
0128:26 H67 N F.
0128:27 w51 I'll switch him thanks.
0128:35 H67 SEA ISLE CAMRN ninety nine line.
0128:38 w59 'SEA ISLE.
0128:39 H67 Ah who's your next one.
0128:40 w59 Ah November four two two Alfa Whiskey.
0128:43 H67 Alright ah if, if you'll take a look at

CASINO its Clipper eighteen tvelve
alright.
0128:48 w59 Yeah.
0128:49 H67 He's turning now for Kennedy.
0128:SO w59 Yeah.
0128:Sl H67 Alright put him twenty in trail behind

him and I'll take him radar contact.
0128:53 w59 Alright Fox (unintelligible).
0128:54 H67 Alright N F if you need to, one more

spin and I'll let you knov on the rest.
0129:58 w59 I'm sorry I didn't catch the last part.

187
0129:oo H67 If you need to, give him one more turn
ah its fine and I'll let you know pn the
rest.
0129:04 w59 Alright twenty in trail Clipper ok Fox

(unintelligible).
0129:06 H67 N F.
0129:09 H67 I'm sorry say again.
0129:ll UNK This is ninety nine Pottstown four three

Bravo echo.
-----------------------------------------------------------------
This portion of the transcript concerns the recorded Position
Relief Briefing between controller **NF** and on-coming controller
"PT" .
0129:44 NF Ok Jeff ve*re coming out of the hold

right now. Ah they want twenty in
trail, two ten on the speed.
NF YOU can't hear what I'm saying? (pause)

How's that?
NF Line check,
UNK Hello.
PT Loud, loud and clear I gotcha ok go

ahead on the override.
NF Twenty in trail.
PT Right.
NF Two ten on the speed.
PT Yes.
NF We're emptying out the holding pattern.

Twenty seven four.
188
PT Alright.
NF ,s Urn there in and out of a.hold missed

approaches and they say stop em ok.
PT Alright.
UNK Urn.
PT In and out ok.
NF Yeah what the plan is (unintelligible) I

told CASINO we'd take there first one
which is the Clipper right here.
Which Clipper?
PT Clipper ah eighteen twelve. Alright.
NF Ok he's radar contact I called CASINO,

and I said, I pointed out this, and I
said put him twenty in trail radar
alright we're gonna have to I think type
him in again he's not stored anymore
PT Alright.
0131:oo NF Alright and ah yeah coded track so were

gonna have to type him in again. I said
we'd get back to him on the rest. What
our plan is is to just follow the
sequence over here alright. We'll take
the first that that was my plan unless
you want to work something out like
maybe urn you vant to empty out CASINO
cause there right here and then go let
CAMRN run normal but its tventy in trail
whatever, whatever you and
(unintelligible).
PT What else could I do?
NF And ah I guess that's it

(unintelligible).
189
PT Alright.
This completes the Position Relief Briefing
-___------------_------------------------------------------------
0131:38 H67 CASINO MANTA eighty one I meant CAMRN.
0131:45 w51 CASINO are you taking Kennedy's?
0131:47 H67 Ah ha ha.
0131:48 w51 Ha ha.
0131:49 H67 Listen you got Pan Am eight eighteen

left down there whats he doin?
0131:so w51 Oh man I don't know what he's going to
do I just sat down here.
0131:53 H67 Ah, well I got I'll tell you vhat we can
slide him in underneath everybody.
0131:56 w51 Alright, at nine or something.
0131:57 H67 Ah he can come in at eleven that'11 be

fine.
0131:59 w51 Eleven, alright we'll move em out of the

way to get him down to eleven.
0132:Ol H67 Ok.
0132:Ol w51 RC.
0132:02 H67 Alright PT.
0133:19 w59 CAMRN uh SEA ISLE ninety nine.
0133:21 H67 Yes.
0133:23 w59 Are you taking em twenty miles in trail

now or are you just gonna take Alfa
Whiskey from us.
190
0133:25 H67 Ah you know ve were just, we were just

discussing that ah who whose the next
guy you got in there Air Mexico.
0132:32 w59 Air Mexico.
0132:33 H67 Ok I'll take Air Mexico four oh six

twenty miles in trail and I'll get back
to you on the rest (unintelligible).
0132:36 w59 Alright. Alright thanks.
0132:38 H67 PT.
013'2 : 59 H67 Hey CASINO CAMRN eighty one.
0133:oo w51 Yeah.
0133:Ol H67 You got Pan AM one seventy one down

there too.
0133:02 w51 Yeah we're going to dump him to nine and
give him to CAMRN. He's, will that
work?
0133:04 H67 Ahhh yeah just ah give us alot of

spacing there (unintelligible1 we
eventually both work him.
0133:09 w51 Yeah right ah alright we're gonna let

the other one hold for a bit we just got
him stuck on top of everybody, yeah ok
(unintelligible) are you running them in
the props.
0133:17 H67 Yeah the props no problem.
0133:18 w51 Ok ok we'll stay probably like twenty in

trail or so.
0133:21 H67 Yeah they go at eight and the ah let's

go at eleven over CAMRN they got a
different set up there.
0133:25 w51 What's the deal vith the jets.

191
0133:26 H67 Ah tell ya what, reduce, we're still

lookin at it I got two comin from/SEA
ISLE, I got one from you from CASINO and
ah I'll let you know whqn I can take
something here. It should be goin up I
got to alternate between the both of you
guys l
0133:35 w51 Right ok.
0133:36 w51 RC.
0133:37 H67 Ok PT.
0133159 H67 Kennedy CAMRN six handoff.
0134:14 H67 Kennedy CAMRN six.
0134:21 N90 Hey hold Avian-:a we'll take him in a

minute.
0134:24 N90 co.
0134:24 H67 PT.
0134:38 w59 CAMRN ninety nine line SEA ISLE handoff.
0134:39 H67 Yeah.
0134:40 w59 Yeah south of BOTON code of one zero

five four is four two two Alfa Whiskey.
0134:43 H67 Ah just south of Atlantic City you said.
0134 : 4'5 w59 Yeah.
0134:46 H67 Ok he's radar contact.

0134:47 w59 Thanks BD.
192
0134:54 H67 Hey Kennedy CAMRN six.
0135:Ol N90 Ok CAMRN the problem is these guys are

comin over and they don't have the RVR
could you make sure they know its two
thousand four hundred.
0135:06 H67 Two thousand four hundred

(unintelligible).
0135:08 N90 Right and we don't want them unless they

can take it cause like we're getting
guys who can't take it and we gotta spin
em.
0135:ll H67 Ok I understand ah just watch Avianca

zero five two in his turn he may just
cut your corner.
0135:lS N90 Yeah that's fine approved.
0135:16 H67 Alright PT.
.
0135.58 H67 Hey Kennedy CAMRN six are you still on
thirteen left?
0136:02 N90 We haven't been on thirteen since we got

here twenty two left all day.
0136:OS H67 OKI just got here. What category is

that over there?
0136:09 N90 Uh lets see.
0136:lO H67 You know?
0136:12 N90 They need an RVR of eighteen hundred if

they're real pilots but a lot of these
guys need forty five.
0136:lS H67 Yeah you know, you know if category it
is their asking for the category.
193
0136:18 N90 Oh ok hold on.
0136:21 H 6 7 Be right with you man.
0136:23 UNK Ok I'm waiting.
0136:24 UNK Hey CAMRN ah disregard.
0136:32 N90 Ok we I guess this is category one

there's nothing special about it.
0136:35 H67 Ok category one Avianca zero five two
can I come around with him on a forty
heading.
0136:39 N90 Ahh not right now cause we're getting

missed approaches again, just keep him
(unintelligible).
0136:41 H67 Ok I'll be ah holding in the hold you

tell me when y:u can take these guys.
0136:43 N90 Ok thank you. DX.
0136:47 H67 He said go back in now, he just said it

to me go ahead on the override.
0136:49 H66 (Unintelligible) ah I just want to let

you know we're holding at nine under
(unintelligible).
0136:59 H67 Wilco.
0137:33 H67 SEA ISLE CAMRN ninety nine.
0137:35 w59 SEA ISLE.
0137:36 H67 I'm back in the hold again.
0137:38 w59 Can you take Air Mexico four oh six.

0137:39 H67 Yeah yeah I can take him.
0137:40 w59 Ok BD.

194
0137:41 H67 PT.
0137:55 H67 CASINO CAMRN (unintelligible).
0137:57 w51 CASINO.
0137:58 H67 I'm back in the hold again I don't know

how long it will be it indefinite.
0138:OO w51 Alright.
0138:OO H67 This guy is killing me.
(0139)
(0140)
(0141)
0142:27 w59 CAMRN ninety nine line SEA ISLE.
0142:29 H67 CAMRN.
0142:30 w59 My next EFC's at zero one five zero how

far should I delay that?
0142:33 H67 Ah delays indefinite I've got four in

the stack now and there's no end in
sight I can say indef I can't give you
times I'd be guessing if I did.
0142:39 w59 Thirty minutes you say.
0142:40 H67 Ah you're guess is as good as mine.

0142:41 w59 Ok.
0142:42 H67 PT.

195
0143:37 N90 Hey CAMRN WATER you can run ah Avensa in

and another one twenty in trail. Do./ you
have anything comin up behind Avensa
water?
0143:47 H67 Ah there on the line there what do you

want Avensa five twenty run him in.
0143:49 N90 Yeah and well take one twenty in trail
behind him at CAMRN, but we need twenty
behind him.
0143:53 H67 Ok I'll tell him we're gonna need

vectors.
0143:55 H66 Hey Avensa five twenty I can't flash him

you have radar on him five miles south
of CAMRN.
0143:57 N90 He's radar forty heading.
0143:59 H66 Show it.
0144:oo N90 BL.
0144:07 H67 And CAMRN gonna start running twenty in

trail (unintelligible).
0144:02 N90 No we're just taking one right now.
0144:04 H67 Ok.
0144:os N90 BL.
0146:24 H67 And Kennedy CAMRN six.
0146:26 N90 Kennedy.

0146:27 H67 Avianca zero five two just coming on
CAMRN can only do five more minutes in
the hold you going to be able to take
him or I'll set him up for his
alternate.
0146:31 N90 What's his speed now?

196
0146:33 H67 Ahh, I'm not to sure, be quite h-onest

with you, holding speed.
0146:35 N90 Slow him to one eighty and I'll take
him.
0146:37 H67 Say again.
0146:38' N90 Slow him to one eight zero knots and

I'll take him he's radar three southwest
of CAMRN.
0146:41 H67 One eighty on the speed radar contact

and I'll put him on a forty heading.
0146:43 N9 0 That's good.
0146:44 H67 PT.
0147:39 w59 CAMRN SEA ISLE ninety nine.
0147:43 H67 Yes.
0147:44 w59 Any ideas how long the delays are gonna
be?
0147:46 H67 I spoke to someone else over there no

idea I'm holding over here delays
indefininte due to weather traffics ah
missing the approaches. they're going
around I just can't give you a good
answer your guess would be as good as
mine that's the best I can tell you.
0147:58 w59 MY, my guess vould probably be better

than yours.
0148:OO H67 Yeah probably this Vernon.
0148:Ol w59 Yeah.
0148:02 H67 Hov ya doin?

197
0148:04 HG7 You guys holding a lot 3r what?
0148:OS w59 Ahh we're holding all up, all up and

down the coast man.
0148:07 H67 Ah that's good, good practice.
0148:08 w59 Alright talk to ya later.
0148:09 H67 See ya.
0148:21 w51 CAMRN eighty one CASINO.
0148:23 H67 Yeah.
0148:24' w51 I see ya took ah Pan Am eight eighteen

ah you want to flash him onto MANTA.
C148:?7 H67 Ah he's already flash to MANTA they got

the handoff on him.
0148:29 w51 Oh ok great how bout jets just give me

an update if you could.
0148:?2 H67 Ah what time did the Saudi go into the

hold let me ask you that.
0148:34 w51 Ah an hour ago.
0148:35 H67 An hour ago.
0148:36 w51 Yep.
0148:37 H67 Ahh hang on a second 1'11 take the Saudi

Air.
0148:39 w51 You're gonna take him.

198
0148:41 H67 Yeah and go to one four thousar,d

alright.
0148:42 w51 Ah yeah ok when he swings out he'll be

going to fourteen.
0148:45 H67 Ah, ok thanks.
0148:46 w51 RC.
0149:os N90 (Unintelligible).
0149:06 H67 Hello.
0149:07 N90 Expect another three zero minute delay

for ones you got left.
0149:lO H67 Ah thirty minute delay what was the last

part you said.
0149:12 N90 Yeah ah for th? aircraft we haven't
taken yet.
0149:14 H67 Ok thirty minute PT.
0149:22 H67 Hey Vernon on the ninety nine.
0149:25 w59 Yeah.
0149:26 H67 They just told me another thirty minutes

and I got for in the stack it will take
me about ten minutes fifteen minutes to
get those guys out so it looks like
about forty five minute delay.
0149:32 w59 Forty five minutes until you can take

one from us.
0149:33 H67 Right.
0149:34 w59 Alright thank you. (Unintelligible)
(0150
199
'I.'his transcription covers the time period from January 26, 1990,
fll.42 UTC to January 26, 1990, 0208 UTC.
Agencies Makinu Transmissions Abbreviation
New York Approach CAMRN Sector CAMRN

American Airlines Flight 692 AAL
Pan American Airways Flight 474 PAA
US Air Flight 117 USA117
Avensa Aerovias Venezolanas S.A.
Flight 520 AVE520
American Airlines Flight 40 AALIO
New York Air Route Traffic Control
Center ZNY
Avianca Aeroovias Nacionales de
Columbia S.A Flight 052 AVA052
Evergreen International Airlines
Flight 102 EIAlO2
New York Approach Islip Sector
Landline Coordination with
unidentified position/sector UNK
El Al Israeli Airline Flight 842 ELY842
I HEREBY CERTIFY that the following is a true transcription of

accident.
c /a
William C. Fetter
System Effectiveness Snecialist
I
200
0142:30 CAMRN American six ninety two descend and zaintair,

five thousand contact approach ah an cne one
eiGht point fctir
Ol?d:08 AAL Five thousand i3ne one eight point tour six
ninety two good night
0142:09 CAMRN Night
0142:16 CAMRN Clipper four seventy four reduce speed 3ne

eight zero
0142:21 PAA 4 Going to one eight zero Clipper four seven

f9ur
(0143)
0143:03 CAMRN US Air one seventeen turn left one five zero
0143:06 USA117 One five zero US Air one seventeen
0143:56 CAMRN Clipper four seventy four turn right heading

zero six zero
0143:58 PAA Zero six zero Clipper four seventy four
0144:19 CAMRN US Air one seventeen descend and maintain

seven thousand special weather at zero one
four two it's indefinite ceiling two hundred
sky obscured visibility is one quarter light
drizzle and fog wind one eight zero at two
two gusts two eight the RVR two thousand
eight hundred two two left
0144:34 USA117 US Air one seventeen seven thousand
0144:38 CAMRN Did you copy the weather
0144:39 USA117 Affirmative sir

201
0144:40 CAMRN Clipper four seventy four did you copy that
special
0144:41 PAA Affirmative four seven four
0144:43 CAMRN Appreciate it thanks
0144145 AVE520 New York approach good evening Avensa five

two zero with Yankee at niner thousand
31411r5l CAMRN Avensa five twenty New York approach thank

you ident proceed direct Deer Park expect ah
VOR runway one three correction expect an ILS
two two left Kennedy altimeter ah two niner
six niner
(0145)
0145:06 AVE520 Direct Deer Park expecting ILS two two left
two niner six niner on (unintelligible) five
two zero
0145:12 CAMRN Clipper four seventy four descend and

maintain five thousand contact approach on
one eight point four
0145:18 PAA Down to five thousand over to eighteen four

Clipper four seventy four good night
0145:22 CAMRN Good night - - US Air one seventeen turn left

heading zero two zero
0145:27 USA117 Zero two zero US Air one seventeen
0145:38 AAL And New York approach American forty heavy

one nine zero with Yankee
0145:42 CAMRN Avensa five twenty descend and maintain seven

thousand
202
i>145:47 AVE520 Descend and maintain seven thousand Avensa

five two zero
0145:Sl CAMRN American forty heavy New York approach good

evening fly heading one eight zero descend
and maintain one six thousand Kennedy
altimeter two niner six niner expect an ILS
runway two two left
0146:OO AAL Okay one eight zero on the heading and ah

descend to one six thousand and say the
altimeter again
0146:04 CAMRN Kennedy altimeter two niner six niner

American forty
0146:07 AAL Two nine six nine thank you American forty
heavy right to one eighty
0146:ll CAMRN Avensa five twenty reduce speed one eight

zero verify you have information ah Yankee
0146:lS AVE520 We have Yankee and reducing to one eight zero

knots five two zero
0146:26 CAMRN Kennedy
0146:27 ZNY Avianca zero five two just coming on Cameron

can only do five more minutes in the hold
think you'll be able to take him or I'll set
him up for his alternate
0146:30 CAMRN What's his speed now
0146:32 ZWY Ah I'm not too sure be quite honest with you
his holding speed
0146:35 CAMRN Slow him to one eighty and I'll take him
0146:37 ZWY Say again

203
0146~38 CAMRN Slow him to one eight zero knots and I'll
take him he's radar three southwest of
Cameron
One eighty on the speed radar contact and

I'll put him on a forty heading
!,-I46 : 4.: CAMRN That's good
0146:44 ZNY Alright (unintelligible)
014'1 : O/i CAMRN Yes ya’am
0147:0'1 UNK Yea I got a little Pan Am there at eight

thousand south of ZIGGY just keep an eye on
him and if he fits into your flow at any
point just ah give me the high sign
0147:l.l CAMRN I'll let you know
0147:12 UNK Alright thanks (unintelligible)
0147:15 CAMRN US Air one seventeen turn right zero five

zero
0147:19 USA117 Zero five zero US Air one seventeen
0147:21 AVA052 New York approach Avianca zero five two heavy
we have information Yankee with you one one
thousand
0147:27 CAMRN Avianca zero five two heavy New York approach
thank you reduce speed to one eight zero if
you're not already doing it you can expect an
ILS two two left altimeter two niner six
niner proceed direct Deer Park
204
014'1: 35 AVA052 Okay direct Deer Park maintaining one eight

zero knots
US Air one seventeen reduce speed one eight

zero
L) 14 '7 ( ,i 1. USA117 Hundred and eighty knots US Air one seventeen
0147:$8 CAMRN American forty heavy descend and maintain one

three thousand leaving one six thousand
reduce speed two one zero
oplj7 Iji;j AAL Okay ah descend to one three thousand and out
of one six thousand slow to two one zero
American forty heavy
(0148)
0148:23 CAMRN Avianca zero five two descend and maintain

seven thousand
0148:27 AVA052 Descending to seven thousand Avianca zero

five two heavy
0148:44 CAMRN US Air one seventeen turn right heading zero

nine zero descend and maintain five thousand
0148:48 USA117 Zero nine zero five thousand US Air one

seventeen
(0149)
0149:21 EIAlO2 New York approach Evergreen ah one zero two

heavy with you level two zero zero
0149:22 CAMRN Ah who is that now
00149:24 CAMRN Evergreen one zero two return to center

frequency please and remain in the holding
pattern'
205
:')119:31 EIAlO2 Roger
'1?4$: 32 ELY842 New York approach El Al eight forty r.wo heavy

maintaining one nlner zero
0149:41 CAMRN El Al eight forty two heavy New York approach

turn right heading one seven zero maintain
flight level one niner zero expect an ILS two
two left
0149:44 ELY842 Okay one seven zero maintaining one niner

zero two two left
0150:18 CAMRN American forty heavy reduce speed one eight

zero
0150:20 AAL Reduce to one eight zero American forty heavy
0150:55 CAMRN El Al eight forty two heavy descend and

maintain one six thousand Kennedy altimeter
two niner six niner
0151:oo ELY842 One six thousand altimeter one two niner six
niner El Al eight four two
0151:25 USA117 New York US Air one seventeen how long can we
ah expect to continue before approach
clearance
0151:36 CAMRN You can expect about another thirty miles

before you touch down at least
0151:43 CAMRN Ah base leg in about twelve miles US Air one

seventeen
0151:48 USA117 Kay

I
206
OfSl:5!, CAMRN Avensa five twenty descend and maintain five

thousand
015E:5.3 AVE520 Descend and maintain five thousand Avensa

five two zero
0152:OO CAMRN El Al eight forty two heavy reduce speed two

one zero leaving one seven thousand please
0152:04 ELY842 Reducing two one zero El Al eight four two
015Z:O8 CAMRN Islip Kennedy point out
0152:ll ISP Go ahead
0152:13 CAMRN At Captree Bridge I'm eastbound right now I

might have to borrow some airspace overhead
your place at five if that's alright with US
Air one seventeen
0152:18 CAMRN Say again
0152:19 ISP (Unintelligible)
0152:20 CAMRN M E
0152:28 CAMRN Avensa five twenty turn right heading zero

nine zero
0152:31 AVE520 Right heading zero nine zero Avensa five two
zero
0152:57 CAMRN US Air one seventeen turn left heading zero

four zero contact approach one one eight
point four
0153:oo USA117 Zero four zero eighteen four US Air one

seventeen
207
015.3:12 CAMRN American forty heavy descend and maintain

eight thousand
015.3; LQ AAL Out of one three thousand for eight thousand

0153:Stj CAMRN Avensa five twenty ah wind shear on two two

left its an increase of ten knots at fifteen
hundred feet and a1so.a wind shear at ah
increase ah ten knots at five hundred feet
reported by seven twenty seven
0154:07 AVE520 Five two zero roger
0154:ll CAMRN Kennedy
0154:13 UNK Do you want a heading for this Evergreen like

a one ninety
0154:14 CAMRN Yes that's fine
0154:16 UNK Okay one ninety here he comes
9154:20 CAMRN ME
0154:23 CAMRN Avianca zero five two turn right heading zero
nine zero
0154:27 AVA052 Turning right heading zero nine zero Avianca

zero five two
0154:33 EIA102 And New York approach Evergreen one oh two

heavy with you one nine zero
0154:40 CAMRN Avianca zero five two turn right right turn
heading two two zero I'm going to have to
spin you sir
208
0154: 45 AVA052 Okay heading two two zero Avianca zero five
two
1:154:52 ELY842 El Xi eight four two maintaining sixteen

thousand we are a heavy we'll need ah Tore
space
?155:00 CAMRN El Xl eight forty two heavy descend and

maintain eight thousand thank you
r)155:05 ELY842 Down to eight thousand El Al eight four two
,155:07 EIA102 Ah approach Evergreen one zero two heavy is

with you one nine zero
0155:ll CAMRN Ah say again please
0155:13 EIAlO2 Evergreen one zero two heavy at level one

niner zero
0155:18 CAMRN Evergreen one zero two heavy New York thank
you expect an ILS runway two two left
0155:21 EIA102 Yes sir
0155:27 CAMRN Avianca zero ah correction Avensa five twenty

turn left heading zero four zero
0155:30 AVE520 Left heading zero four zero Avensa five two
zero
0155:34 CAMRN Islip Kennedy
0155:35 ISP Islip's on
0155:36 CAMRN Over the Captree again Avensa five twenty

northeast bound at five
0155:37 ISP Point out approved

209
3 1 5 $. .j 8 CAMRN M E
11.5'5: 48 CAMRN Avensa five twenty contact approach cne one

eight pint four
ljl!jS: 50 AVE520 One one eight point four so long
:) 1 5 !-; ; s 2 CAMRN Avianca zero five two traffic in your turn

twelve thirty and five miles eastbound at six
thousand
i;ilSri : OG AVA052 Avianca we have the traffic in sight thank

YOU
')lsc,:oi CAMRN Roger
0156:0‘? CAMRN Evergreen one zero two heavy descend and

maintain one six thousand
0156:12 EIA102 Ah leaving one nine for one six thousand

Evergreen ah one zero two heavy
0156:15 CAMRN Avianca zero five two I have a wind shear for
you ah at fifteen ah increase of ten knots at
fifteen hundred feet and then an increase of
ten knots at five hundred feet reported by
seven twenty seven
0156:26 AVA052 Thank you very much Avianca zero five two
0156:48 CAMRN American forty heavy descend and maintain

seven thousand turn right heading two zero
zero
0156:53 AAL Okay ah right to two zero zero and out of

eight for seven
0156:58 CAMRN American forty affirmative receive delaying

vectors for final
0157:oo AAL Roger

210
0157;03 CAMRN And El Xl eighty forty two heavy turn right

heading two zero zero ah delaying vectors
015 7 : (I'? ELY842 Heading two zero zero El Al eight forty two
015.': d4 AAL New York approach American four heavy one

nine zero we're heading direct to ah
LaGuardia with Yankee
0157:so CAMRN American four heavy roger you can expect an

ILS two two left altimeter two niner six
eight
0157:55 AAL Nine six eight two two left American four
heavy
(0158)
0158:18 CAMRN Evergreen one zero two heavy reduce speed two
one zero
0158:22 EIA102 Roger two one zero Evergreen two zero one
0158:43 CAMRN Avianca zero five two turn right heading zero
six zero
0158:45 AVA052 Turning right heading zero six zero Avianca

zero five two heavy
(0159)
0159:lO CAMRN American four heavy turn right heading one

niner zero descend and maintain sixteen one
six thousand altimeter two niner six eight
0159:20 AAL Two nine six eight down to one ,six thousand
and ah one ninety on the heading American
four
211
0?%3:22 CAMRN El Al eight forty two heavy descend and

maintain seven thousand
I) 1 '7 3 I 2 6 ELY842 Down seven thousand El Al dight forty two
c-ltsg* 31 CAMRN American forty heavy turn left heading zero

two zero
OISY:34 AALQO Left zero two zero American forty heavy
015q;40 CAMRN Evergreen one zero two heavy descend and

maintain one three thousand
015'3:44 EIA102 One three thousand Evergreen ah zero one

heavy
(0200)
02OO:OS CAMRN Avianca zero five two stop turn heading zero
four zero
0200:08 AVA052 Ah zero four zero Avianca zero five two heavy
0200:17 CAMRN Evergreen one zero two you can expect a few
delaying vectors turn left heading one five
zero
0200:21 EIAlO2 One five zero one zero two heavy
0200:25 CAMRN American four heavy leaving one seven

thousand reduce speed two one zero
0200:29 AAL Okay two ten out of one seven thousand

American four heavy
(0201)
02Ol:lS CAMRN Avianca zero five two descend and maintain

five thousand
212
0201:18 AVA052 Descend and maintain five thousand Avianca

zero five two
3201324 CAMRN Evergreen one zero two reduce speed cne eight
zero
0201:27 EIA102 One Gight zero cne zero two heavy
0201:32 CAMRN El Al eight forty two heavy reduce speed one

eight zero
0201:35 ELY842 One eight zero reducing El Al eight four two
0201:43 CAMRN Xvianca zero five two turn right heading zero
nine zero
0201:47 AVA052 Right heading zero nine zero Avianca zero

five two
02Ol:Sl CAMRN American forty heavy turn right heading zero

seven zero
0201:56 AAL Zero seven zero American forty heavy
(0202)
0202:07 CAMRN El Al eight forty two heavy turn left heading

zero nine zero
0202:12 ELY842 Left zero nine zero El Al eight four two
0202:14 CAMRN Evergreen one zero two heavy turn right

heading two two zero
0202:18 EIA102 Two two zero one zero two heavy
0202:22 CAMRN Evergreen one zero two affirmative and

descend and maintain eight thousand
213
0202:23 EIA102 Ah leaving one three for eight thousand

Evergreen ah one zero two heavy
0202:26 CAMRN Avianca zero five two turn left heading zero
four zero
320:2'3 AVA052 Left heading zero four zero Avianca zero five
two
0202:38 CAMRN Avianca zero five two heavy approach one one
eight point four
0202'42 AVA052 One one eight point four so long
il202:44 CAMRN Avianca zero five two and before YOU go there
is a wind shear alert on final at fifteen
hundred feet it's an increase of ten knots
then again at five hundred feet increase of
ah ten knots by a seven twenty seven New York
now on one one eight point four good night
0203:OO AVA052 One eighteen four
0203:02 CAMRN American forty heavy turn left zero four zero
0203:06 AALIO Left zero four zero American forty heavy
0203:08 CAMRN American four heavy descend and maintain one

three thousand
0203:09 AAL One three thousand American four heavy
0203:28 CAMRN American forty heavy correction four heavy

you can expect the few delaying vectors turn
left heading one five zero
0203:30 UL4 Roger one five zero American four heavy
0203:39 CAMRN El Al eight forty two heavy turn left heading

zero four zero
214
3203:42 ELY842 Heading zero four zero El Al eight forty two
02!14:03 CAMRN American forty heavy wind shear on final it's

an increase of ten knots at fifteen hundred
and then again at five hundred an increase of
ten--knots seven twenty seven
0204:OS AAL Ah we copy that thank you American forty

heavy
0204:54 EIA102 And approach an confirm speed you want

Evergreen one oh two at
0205:OO CAMRN Sorry what was that
0205:Ol EIA102 Evergreen one oh two confirm the airspeed you

want us to fly right now
0205:06 CAMRN Hundred and eighty knots Evergreen one zero

two
0205:09 EIAlO2 Okay thank you
0205:16 CAMRN American forty heavy turn right zero nine

zero
3205:19 AAL Right zero nine zero American forty heavy
0205:35 CAMRN American forty heavy descend and maintain

five thousand
0205:38 ML40 Left seven for five American forty heavy
(0206)
0206:lO CAMRN American forty heavy turn left heading zero

six zero
0206:16 AAL Left zero six zero American forty heavy

215
0206:18 CAMRN Evergreen one zero two turn left heading one
two zero
One two zero one zero two
0206 : 2.3 CAMRN American four heavy descend and maintain

eight thousand
0206:;25 AAL Down to eight thousand American four heavy
0206:35 CAMRN American forty heavy contact approach one one

eight point four
0206: 39 AALIO Eighteen four American forty heavy
0206:47 CAMRN Evergreen one zero two descend and maintain

seven thousand
0206:50 EIAlO2 Down to seven thousand one zero two heavy
0207:OO CAMRN American four heavy turn right heading two

one zero
0207:02 AAL That's two one zero American four heavy
0207:05 CAMRN El Al eight forty two heavy wind shear on two

two left ah it's an increase of ten knots at
fifteen hundred feet and an increase of ten
knots at five hundred feet reported by seven
twenty seven
0207:19 ELY842 Okay eight four two
0207:50 CAMRN El Al eight forty two heavy turn right

heading zero seven zero descend and maintain
five thousand
0207:54 ELY842 Right zero seven zero and cleared now to five
thousand eight four two
End of Transcript
216
This transcription covers the time Period from January 26, 1990,
0158 UTC to January 26, 1990, 0238 UTC.
Agencies Makinff Transmissions Abbreviation

New York TRACON Final Vector FV
Air France Flight 26 AFR26
U. S. Air Flight 117 USA117
Pan American Airlines Flight 474 PAA
Pan American Commuter Flight 793 Pxx793
Avensa Aerovias Venozolanas S.A.
Flight 520 AVE520
Avianca Aerovias Nacolales de
Columbia S.A. Flight 052 AVA052
Trans World Airlines Flight 801 TWA801
El Al - Israeli Airlines Flight 842 ELY842
Evergreen International Airlines
Flight 102 EIAlO2
Pan American Airlines Flight 11 PAAll
Recorded Transmissions from an
Unknown Source UNK
accident.
L2iuzLC#&
William C. Fetter
System Effectiveness Specialist
(0158)
217
0158:04 F V Air France zero two six heavy turn left

heading two five zero intercept the localizer
0158:09 AFRO26 Heading two five zero to intercept iocalizer

Air France zero two six heavy
0158:lO FV US Air one seventeen descend and maintain

three thousand
0158:16 USA117 Five for three US Air one seventeen
0158::8 F V Clipper four seventy four turn left heading

one five zero I'm going to put you right back
in the sequence sir
0158:23 PAA One five zero Clipper four seventy four thank
YOU
(0159)
0159:17 AAL Ninety two very unhappy at two thousand feet
0159:20 F V American six ninety two New York I understand

maintain two thousand fly heading one uh one
four zero for now
0159:26 AAL Okay one forty at two thousand American six

ninety two
0159:29 F V American six ninety two climb and maintain

three thousand you're number five I'll make
sure you get a lot of room there
0159: 36 AAL Maintain three thousand you say three

thousand American six ninety two
0159:39 F V Affirmative sir
0159:40 UNK Alright

218
0159:53 F V US Air one seventeen turn left heading two

eight zero
0159:56 USA117 Two eight zero US Air one seventeen
(0200)
0200:07 F V Air France zero two six heavy contact Kennedy

Tower one one niner point one good day
0200:12 UNK One nineteen one good day
0200:15 FV Clipper four seventy four turn left heading

zero five zero
0200:18 PAA Zero five zero Clipper four seven four
0200:23 PXX793 Un approach do you want Pan Am seven ninety

three over to tower
0200:25 FV Pan Am seven ninety three contact Kennedy

Tower one one niner point one good evening
0200:29 UNK Good night sir
0200:30 FV US Air 3ne seventeen Cum left heading two

five zero you're one five miles from the
outer marker maintain two thousand until
established localizer cleared ILStwo two
I
left
0200:39 USA117 Cleared to the ILS to two two left US Air

one seventeen
0200:54 USA117 What's the spacing on the traffic ahead for

US Air one seventeen
0200:57 F V Heavy jet eight miles

219
FV Avensa five twenty Cum ieft heading two six

zero
0201:35 AVE520 Left heading two six zero Xvensa five two
zero
0201:42 FV American six ninety two turn left heading

zero six zero
0201:47 AAL Left to zero six zero american six ninety two
'J201:51 FV Avensa five twenty descend and maintain two

thousand
0201:54 AVE520 Descend and maintain two thousand Avensa five

two zero
AAL American six ninety two I want to advise you

we're at minimum fuel uh we're uh about uh
twelve or fourteen minutes from declaring an
emergency
0202:08 F V I understand uh you're number four with me

sir
0202:ll UNK Ok
0202:16 F V Clipper four seventy four turn left heading

three three zero speed uh one seven zero
if you're not back
0202:21 PAA Three three zero slow to one seven zero

Clipper four seven four
0202:36 FV American six ninety two I‘m going to take you

another eight miles where you are then turn
ya to the final
0202:42 UNK Roger

220
0202:48 FV Avensa five twenty speed one six zero
0202:51 AVE520 Six zero on the speed Avensa five two zero
(0203)
0203:07 AVA052 New York approach Avianca zero five uh two

leveling five thousand
0203:ll FV Avianca zero five two heavy New York approach

good evening fly heading of zero six zero
9203:16 AVA052 Zero six zero Avianca zero five two heavy
0203320 FV US Air one seventeen contact Kennedy Tower

one one niner point one good day
0203:26 USA117 One seventeen good night
02r?3:28 FV Good night
0203335 FV Clipper four seventy four turn left heading

two seven zero
0203:39 PAA Two seven zero Clipper four seven four
3203:41 FV Avensa five twenty turn left heading of two

five zero you're one four miles from outer
marker maintain two thousand till established
localizer cleared ILS two two left
0203:50 AVE520 Heading two five zero maintain two thousand

till established cleared ILS two two left
Avensa five two zero
(0204)
0204:26 F V Clipper four seventy four descend and

maintain two thousand
I
221
0204:30 PAA Down to two thousand Clipper four seventy

four
0234:33 F V American six r,inety two turn left heading

three two zerc
c)204:36 AAL Three two zero American six ninety two
(0205)
0205:12 F V Avianca zero five two heavy turn left heading

three six zero
0205:16 AVA052 Left heading three six zero Avianca zero

five two heavy
0205:20 F V American six ninety two turn left heading of

two seven zero
0205:23 AAL Left to two seventy American six ninety two
0205:25 F V Clipper four seventy four turn left heading

two five zero you're one five miles from the
outer marker maintain three thousand till
established on the localizer cleared ILS two
two left
3205:35 PAA Three thousand till established now we will

not pick it back up cleared for the approach
Clipper four seven four
0205:41 TWA801 Approach TWA eight zero one heavy's with you
four thousand
0205:44 F V TWA eight zero one heavy new york approach

good afternoon make it good evening fly
heading zero six zero
0205:49 TWA801 Zero six zero eight oh one heavy
0205:53 F V Avensa five twenty contact kennedy tower one

one nine point one good day
222
0205:57 AVE520 One niner point ,zne good night sir
02?6:c70 F V Avianca zero five two heavy turn lefr :?eading

of three zero zero
0206:04 AVA052 Left heading three zero zero Avianca zero

five two heavy
0206:12 F V American six ninety two how are we making out
0206:15 AAL We got enough fuel for the approach and

landing and that's it
0206:18 F V Ok understand
(0207)
0207:06 AAL Approach American forty heavy's with you

leveling five
0207:09 F V A!?erican forty heavy New York approach good

evening
0207:12 UNK Good evening
0207:16 'V Avianca zero five two heavy turn left heading
two niner zero
0207:20 AVA052 Left heading two nine zero Avianca zero five
two heavy
0207:53 F V TWA eight on one heavy turn left heading two

niner zero
0207:56 TWA801 Left to two nine zero TWA eight oh one heavy
(0208)
0208:16 F V American six ninety two speed one six zero if

practical
223
0208:20 XAL692 American six ninety two roger
0208:34 F V Avianca zero five twc heavy descend md

Tainrain uh descend and maintain three
thousand
C208:40 AVA052 Descend and naintain three thousand Xvianca

zero five two heavy
(0209)
0209:18 F V American forty heavy turn left heading three

one zero
3209:20 XAL40 TYC- ft three zne zero American forty Seavy

two seven zero
0209:47 AVA052 Left heading two seven zero Avianca zero five
two heavy
0209350 F V knerican six ninety two turn left heading two

one zero you're one three miles from outer
xarker maintain two thousand till established
0209:59 AAL Turning to two ten uh two thousand feet

cleared the ILS two two left American uh six
ninety two
(0210)

two five zero intercept the localizer
0210:31 AVA052 Heading two five zero intercept.the localizer

Avianca zero five two heavy
0210~35 F V TWA eight on one heavy turn left heading two

seven zero
224
0219:37 F V Two seven zero TWA eight oh one heavy
?21@:41 F V Cii;per fQ,ur seventy four contact Kennedy

Tower 3ne one niner point one thanks for your
help
'3210:46 UNK Slacked
32:0:48 F V American six ninety two you're six mi12s

behind a seven two seven compatible speed
0210:53 UNK Thank you
0210:55 ELY842 El x1 oight four two maintaining five

thousand
3219:58 FV El X1 eight fifty zwo heavy Ilew York good

evening fly heading of zero two zero
(0211)
02:1:02 ELY842 tleading zero two zero El Al eight four two
0211:06 F V Avianca zero five two heavy you're one five

Tiles from outer Earker r?.aintain two thousand
till established on localizer cleared ILS two
two left
0211:14 AVA052 Cleared ILS two two left maintain two

thousand until established Avianca zero five
two heavy
0211:19 F V American forty heavy turn left heading of two

eight zero
0211:22 AAL Left to two eight zero American forty heavy
0211:24 PAA Want Clipper four seven four to tower
0211:27 F V Affirmative sir tower nineteen one good

evening
225
0211:35 F V TWA eight oh one heavy descend and maintain

two thousand
0211:37 TWA801 TWA eight oh one heavy we'll leave four for
two
021::40 F V American forty heavy descend and maintain

three thousand
0211:43 AAL Out of five for three American forty heavy
0211eG
. -* F V Avianca zero five two heavy speed one six
z2ro if practical
0211:59 AVA052 One six zero Xvianca zero five two heavy
(0212)
0212:Ol F V American six ninety two again thank you for

your cooperation contact Kennedy Tower one
one niner point one good evening
02:2:07 AAL Teen one American six ninety two

(unintelligible)
c1212:15 F V El Al eight forty two heavy turn left heading

three one zero
0212:19 ELY842 Left heading three one zero El Al eight four

two
0212:24 F V TWA eight zero one heavy speed uh say your

indicated airspeed
0212:27 UNK Indicating one eight zero knots
0212:29 F V Ok
0212:57 F V TWA eight zero one heavy turn left heading

two five zero intercept the localizer
226
(0213)
J213:02 TWA801 Two fifty intercept the 19calizer TWA eight

oh one heavy
0213:12 FV TWA eight zero one heavy reduce speed to 9ne

six zero if practical
0213:15 TWA801 We'll slow to one sixty eight oh one heavy
0213:17 F V American forty heavy speed one six zero if

practical
0213:20 XAL40 One sixty American forty heavy
0213:22 'V TWA eight zero one heavy one five Eiles from
outer marker maintain two thousand till
established localizer cleared for ILS two two
left
0213:28 TWA801 TWA eight oh one heavy cleared for the ILS
two two left
0213:36 F V American forty heavy turn left heading of two

six zero
0213:39 AAL Left two six zero American forty heavy
0213:44 F V El Al eight forty two heavy descend and

maintain four thousand
0213:47 ELY842 Four thousand El Al eight four two leaving

five
(0214)
0214:45 ELY842 El Al eight four two maintaining four

thousand
227
0214:47 F V El Al eight forty two heavy turn left heading

two two zero I just want to get uh get you
into the wind to slow you up a little bit
0214:52 ELY842 Reading two two zero El Xl eight four two
0215:OO F V American forty heavy turn left heading two

five zero intercept the locaiizer
0215:06 AAL Left two five zero intercept the localizer

0215:08 F V Avianca zero five two heavy contact Kennedy

0215:12 AVA052 One one niner point one so long
(0216)
0216:48 ELY842 El Al eight four two maintaining heading two

two zero
0216:50 PV Thank you sir I'll have a turn northwest

bound again here shortly I just want to bring
you in closer to the final here
0216:58 UNK Roger
(0217)
0217:46 AAL Kennedy approach American four heavy is out

of uh six thousand four hundred for five
thousand
0217:50 F V American four heavy New York approach good

evening maintain five thousand
0217:54 AAL American four heavy
(0218)
228
0218:16 FV American forty heavy tarn left heading one

eight zero I want to give you a little more
room there
9215:22 AAL One eight zero on the heading American uh

forty heavy
0218:25 FV El Al eight forty two heavy make a left turn

a left turn heading of two seven zero
0218:30 ELY842 Left turn two seven zero El Al eight four two
0218:46 FV TWA eight zero one heavy contact Kennedy

Tower one one niner point cIne good evening
c)218:50 TWA801 TWA eight oh one good night
(0219)
0219:47 EIA102 New York approach Evergreen ah one oh two

heavy is with you out of seven for five
0219:51 FV Evergreen one zero two heavy :few York good

evening
02'Qsc5
*-.- FV American forty heavy turn right heading two
eight zero
0219:57 AAL Right two eight zero American forty heavy
(0220)
022O:Ol ML40 Un American forty are you going to put us on

the localizer and go in
0220:05 FV Yes sir that's why I'm turning you I just

want to make sure you get there the first
time
229
0220:24 F V American four heavy turn left heading of

three one zero
0220:29 AAL Left turn three one zero American four heavy
0220:34 F V American forty heavy descend and maintain two

thousand thank you for your help
0220:39 AALQO Out of there for two American forty heavy

roger
0220:43 ELY842 El A1 eight four two heading two seven zero
0220:45 F V 31 Xl eight forty two heavy New York apprcach

good evening thank you maintain ycu can
descend and maintain three thousand now
please
0220:53 ELY842 El Al eight four two cleared now three

thousand
0220:55 F V Affirmative sir
0220:59 AALIO And you want American forty heavy to

intercept the localizer on this heading
(0221)
0221:Ol F V Americ an forty heavy turn left heading two

four zero you're eight miles from outer
0221:lO ML40 Okay left to two forty two thousand till

established cleared for ILS two two left
0221:35 F V American forty heavy contact Kennedy Tower

one one niner point one good evening
230
0221:41 AAL Nineteen one good evening American forty

heavy
0221:42 FV American four heavy descend and maintain

three thousand heading of two seven zero
0221:47 AAL Okay heading of two seventy three thousand

American four heavy
0221:53 SLY842 El Al eight four two maintaining three

thousand
0221:56 FV Thank you sir
(92221
0222:06 FV El Al eight forty.two heavy turn right

heading three zero zero just want to provide
ya a little extra room
0222:12 ELY842 Heading three zero zero El Al eight four two
0222:15 FV TWA eight uh one heavy if you're with me sir

climb and maintain three thousand fly heading
of one two zero
0222:31 TWA801 Approach TWA eight oh one is with you at two

thousand feet
0222:34 FV TWA eight oh one heavy New York approach

sorry about that climb and maintain three
thousand fly heading of one one zero
0222:40 TWA801 Okay one one zero on the heading back up to

three
0222:42 FV TWA eight oh one you're number four I'll have

a short approach for you
0222:45 TWA801 Okay thanks a lot

231
0222:51 F V El Al eight forty two heavy descend and

maintain two thousand
0222:54 ELY842 (Unintelligible) two thousand El Al eight

four two
(0223)
0223:ll F V El Al eight forty two heavy turn left heading

of two one zero you're nine miles from outer
on localizer cleared for ILS two two left
0223:20 ELY842 ILS two two left C,l Al eight four two
0223:24 TWA801 TWA eight oh one is doing a hundred and eight

knots now is that okay
0223:27 F V Yeah that's good sir
0223:29 F V Evergreen one zero two heavy turn left

heading three three zero
0223:33 EIA102 Three three zero one oh two heavy
0223:55 F V Evergreen one zero two heavy descend and

0223:58 EIA102 Roger leaving five for four Evergreen one oh

two heavy
(0224)
0224:07 DEPT Final departure point out
0224:09 F V Final
0224:ll DEPT Seven seven east Command (unintelligible)

1
232
0224:12 F V Point out approved alpha zulu
0224:33 ELY842 Sstablished El Al eight four two
0224:35 F V Thank you sir
0224:47 F V El Al eight forty two heavy thank you for

your help contact kennedy Tower one one niner
point one
0224:52 ELY842 (Unintelligible) thank you
0224:55 AVA052 Approach Avianca zero five two heavy we just

(missed)* a missed approach and uh we're
maintaining two thousand one five
(unintelligible)
(0225)
0225:02 F V Avianca zero five two heavy New York good

evening climb and maintain three thousand
0225:07 AVA052 Climb and maintain three thousand and uh

we're running out of fuel sir
0225:14 FV Okay ah fly a heading of zero eight zero
0225:16 AVA052 Right heading zero eight zero climb to three

thousand

zero four zero
0225:22 TWA801 Zero four zero TWA eight oh one heavy
0225:41 F V Evergreen one zero two heavy fly heading two

seven zero
0225:44 EIAlO2 Two seven zero one oh two heavy

233
0225:53 F V American four heavy present heading I'll give

you a turn here in a minute
0225:56 AAL American four heavy WILKO
(0226)
0226:08 F V American four heavy turn left heading one

eight zero your nine miles from outer marker
maintain two thousand until established on
the localizer course cleared for ILS two two
left
0226:14 AAL Okay one eight zero two thousand maintain two
until established cleared ILS two two left
American four heavy
0226:21 F V Evergreen one zero two heavy descend and

maintain three thousand
0226:24 EIA102 We're leaving four for three Evergreen one

zero two heavy

zero seven zero
0226:32 AVA052 Heading zero seven zero Avianca zero five two
heavy
0226:36 F V And Avianca zero five two heavy ah I'm going

to bring you about fifteen miles northeast
and then turn you back on for the approach is
that fine with you and your fuel
0226:41 AVA052 I guess so thank you very much
0226:50 F V Evergreen one zero two heavy turn left

heading two five zero you're one five miles
from the outer marker maintain three thousand
until established on the localizer cleared
for ILS two two left
0227:OO EIAlO2 (Unintelligible) cleared for approach

Evergreen one two heavy
234

two nine zero
0227:04 TWA801 Two nine zero TWA eight oh one
0227:28 FV American four heavy contact Kennedy Tower one

one niner point one good evening
0227:30 AAL rlineteen one for American four heavy you have
a good evening sir
0227:35 FV Thank you you too
0227:47 PAA Kennedy approach Clipper eighteen twelve

heavy with alpha's descending to five
thousand heading zero six zero
0227:49 F V Clipper eighteen twelve heavy New York good

evening
0227:51 FV TWA eight zero one heavy turn left heading

two seven zero
0227:55 TWA801 Two seven zero TWA eight oh one heavy
(0228)
0228:12 FV Clipper eighteen twelve heavy descend and

0228:14 PAA Eighteen twelve heavy to four thousand
0228:43 EIA102 And approach Evergreen one zero two heavy is

one seven zero a good speed on final
0228:49 FV Ah what's it going to be in knots I don't

know the math ah
0228:54 EIA102 Ah yes sir a hundred and seventy knots on

final for Evergreen is that okay
235
0228:58 F V Yea that's fine ah just ah I have a heavy jet

seven ahead and he's about twenty knots
slower it's going to due to the winds 1'~.
going to need you to slow about twenty knots
in about three or four miles
(0229)
0229:lO EIAlO2 Okay sir
0229:19 AVA052 When can you give us a final now Avianca zero
five two heavy
0229:22 F V Avianca zero five two affirmative sir turn

left heading zero four zero
0229:25 XVA052 Zero four zero Xvianca zero five two heavy
0229:42 F V Evergreen one zero two heavy contact Kennedy

0229:46 EIA102 Ah good day
0229:56 PAAll New York approach control it's Clipper one

one heavy maintaining four thousand feet
turning right to zero three zero what speed
would you like
(0230)
0230:04 F V Clipper ah eleven heavy New York good evening

speed one eight zero please
0230:09 PAAll Back to one eight zero for eleven heavy

two five zero you're one five mi1e.s from
outer marker maintain two thousand until
established on localizer cleared for ILS two
two left
236
0230:21 (Unintelligible)
0230:26 FV Okay two called Trans World eight oh one you

were cleared for the approach
0230:33 TWA801 Affirmative TWA eight oh one we got it we're

out of three for two
0230:36 FV Avianca fifty two climb maintain three

thousand
0230:40 AVA052 Ah negative sir we we're just running out of

fuel we okay three thousand now we could
0230:44 FV Ckay turn left heading three one zero sir
0230:46 AVA052 Three one zero Avianca zero five two
0230:49 FV Clipper eighteen twelve heavy turn left

heading three one zero
0230:52 PAA Eighteen twelve heavy left three one zero
0230:55 FV And Avianca fifty two fly a heading of

three six zero please
0231:OO AVA052 Okay we're about three six zero now
0231:03 FV Okay you number two for the approach I just

have to give you enough room so you make it
without having to come out again
0231:08 AVA052 Okay we're number two and flying three six
zero now
0231:12 F V Thank you sir
0231:27 F V TWA eight zero one heavy your eight miles

behind a heavy jet contact Kennedy Tower One
one niner point one thanks for your help sir
237
0231:32 TWA801 Okay eight oh one roger and what's his ground
what's his airspeed do you know
0231:35 F V Ah he's indicating ten knots slower eight

miles
0231:38 TWA801 Okay thank you
0231:40 F V Thank you
0231:43 F V Clipper eighteen twelve heavy speed one six

zero if practical
0231:48 PAA Eighteen twelve heavy slowing to one sixty
(0232)

three three zero
0232:ll AVA052 Three three zero on the heading Avianca zero

five two
0232:51 AVA052 Avianca zero five two we just ah lost two

engines and we need priority please
0232:56 FV Avianca zero five two turn left heading two

five zero intercept the localizer
0233:OO AVA052 Roger
0233:07 F V Avianca zero five two heavy you're one

five miles from outer marker maintain two
thousand until established on localizer
cleared for ILS two two left
0233:16 AVA052 Roger (Unintelligible)
0233:18 F V Clipper eighteen twelve turn left heading two

two zero
238
0233:21 PAA Eighteen twelve left two two zero
0233:51 FV Clipper one eleven ah Clipper eleven heavy

turn right heading zero six zero
0233:56 PAAll Right to zero six zero for Clipper eleven

heavy
0234:OO FV Avianca zero five two you have uh you have

enough fuel to make it to the airport
0234:29 FV Clipper eighteen eleven heavy turn left

0234:36 FV Avianca zero five two New York
0234:53 PAA New York Clipper eighteen twelve heading two

two zero
0234:56 FV Thank you sir
0235~00 FV Clipper one eleven heavy Clipper eleven heavy

turn right heading two two zero
0235:04 PAAll Right to two two zero for Clipper eleven

heavy
0235:07 FV That's a right turn heading two two zero
0235:09 PAAll Right turn to two two zero Clipper eleven
0235:26 FV Avianca zero five two radar contact lost
0235:50 FV Clipper eighteen twelve heavy turn left

heading two two zero ah turn left heading one
eight zero
0235:55 PAA One eight zero Clipper eighteen twelve heavy

239
(0236)
0236:21 F V Clipper eleven heavy fly heading one eight

zero contact New York one two five point
seven
0236:26 PAAll One eight zero for Clipper eleven heavy and
one two five seven
0236:28 FV Ah affirmative sir
0236:40 FV Clipper eighteen twelve heavy turn right

0236:45 PAA Eighteen twelve heavy right to two two zero
End of Transcript
240
This transcription covers the time period from January 26, 1990,
0216 UTC to January 26, 1990, 0238 UTC.
Auencies Makina Transmissions Abbreviation
New York TRACON Kennedy Sequencer SEQ
Kennedy Air Traffic Control Tower Tower
accident.
L&Liz* c &%
William C. Fetter
System Effectiveness Snecialist
(0217)
0217:06 UNK Tracon Kennedy
(02181
(0219)
CO220)
(0221)
0221:lO SEQ Yes

241
0221:ll Tower Hello there I think this AW ah TWA eight oh

one's gonna come out Avianca must be puttin
his feet out the window
0221:17 SEQ Okay uh if you have to one uh fifty heading

and two thousand back to eighteen four
0221:22 Tower One fifty two thousand eighteen four thank

YOU
0221:24 =Q D L
(0222)
(0223)
(0224)
0224:03 SEQ Yes
0224:04 Tower Avianca's missing due to the weather thing

(unintelligible) one eighty at two speak to
who
0224:ll SEQ Okay one fifty at two if you can and
0224:ll Tower One five zero okay
0224:16 SEQ And go to eighteen four with him
0224:17 Tower Eighteen point four thank you
0224:18 SEQ D L
(0225)
242
(0226)
(0227)
(0228)
(0229)
0229:41 Tower Tower cab
0229:42 SEQ Yeah Avianca fifty two says he can't go

around so we'll give him plenty of room
0229:46 Tower Okay thanks
0229: 46 SEQ DL
0229:47 Tower Bye bye
0229: 47 =Q (Unintelligible)
(0230)
(0231)
(0232)
0232:50 Tower Tower
0232:51 SEQ Yeah we're uh uh let's see do you know

Robbinsvilles Dixies and Whites are released
0232: 55 Tower Yeah just got the word
0232:56 =Q Ok thanks
I
243
0232:57 Tower (Unintelligible)
(0233)
0233:15 SEQ Yeah Avianca fifty two lost an engine and

we're trying to find out why and get the
personnel and fuel
0233:20 Tower Okay thank you
0233:21 SEQ DL
0233:43 Tower Tracon Kennedy
(0234)
0234:16 SEQ Yeah we're not talking to Avianca any longer

he's fifteen northeast of Kennedy
0234:20 Tower Umhm
0234:21 SEQ Okay so uh if you get him uh he's nordo we

don't know what his altitude what his problem
was he last reported losing an engine
0234:26 Tower Ah wonderful
0234:27 SEQ Okay
0234:27 Tower Thank you
0234:28 SEQ DL
0234:28 Tower A L
(0235)
0235:06 SEQ We lost radar contact fifteen northeast of

Kennedy with Avianca
0235:ll Tower Thank you
0235:12 SEQ D L
(0236)
(0237)
(0238)
(0239)
(0240)
End of Transcript
1
245
3 r&A."
c)l
n 'JTC to January 26, 1990, 0240 UTC.
Aqencies Hakiiis Transmissians Abbreviation
New York TRXCCN N ‘I‘T

Kennedy m-----
I"WC3L Local Control Tower
Xvianca Airlines Flight 052 AVA052
Fan American Airlines Flight 474 F AA374
American Airlines Flight 692 XXL692
American Airlines Flight 4 XAL4
American Airlines Flight 40 n*, nn
d%tkA.I%"
Air France Airlines Flight 026 AFRO26
Avensa Airlines Flig?,t 520 AVE520
USXir Airlines Flight 117 u s A 1 17
m,,
IL ofis World Airlines Flight SO1 TWA801
EL-AL-7&srael Airlines Flight 842 ELY842
Evergreen Airlines Flight 132 ET"
AnA.'1 02
In,
transmissions from an unknown scurce UNK

CL
crre recorded conversations pertaining to the subject aircraft
accident:
2
SUSAN F . FARRELL
Program Specialist
(0210~
(0211)
0211:29 Tower Avensa five twenty, rilnway two two left -wind
one niner zerc at two one cleared to land
0 CI, '!
&A.r:?? Avvc-n
Id-I&" Cleared to land zero -- two one cleared to
land avensa five two zerc
Clipper fc-ur seven fo-ur's ato-ut ten "UL

-s-C
0 211:40 Tower Xvensa five twenty what's yc-ur airspeed now
02:1:42 AVE520 3ne four zero knots
0211-. 45 Tower Alright Clipper four -- seventy four Kennedy

mLower two tWG left number three following
seven two seven traffic a half mile inside
the outer marker
Seven fo-ur rsger
019-l
ALA:54 Tower Air France zerc two six heavy cross runway
two two right taxi ah right on the outer ar
-we.._
straight in Kilo whichever you need YL vUIld
point niner
ncllq.n?
“Cl&b. “48 AFRO26 Cleared tc cross two two right via Kilo and
ah ground point niner for Air France twenty
Siii heavy
Ah Clipper feur seventy fo-ur wind Kindshear

reptrted a loss cf five knots at a thou= and
and a loss of fifteen knots at ah -- five
hundred feet reported by an airbus twc two
left R V R more than six thcusand
0212:20 pa% A 74
IL-- Seven fo-ur roger
0 212 : 22 AAL American's six xiinety two we're fourteen cut

for two two ah left
American six ninety two roger you are number

- - four cn the approach fcllowing seven two
seven traffic -- four miles ahead
1
3212::: Tower American six ninet-1 two rsger
mr.. ..a1.Y
C212:44 ruwer Clipper four seventy four what's J"UA
q-7
._L A --;i 7
02:2:47 FAA 474 one six zero
0212: 48 Tower Alright
Giie 3e *v* e n t 2 e iA via Hotel k=old short cf

Vu' s :, +A r
runway twzl two right and remain this

fr.equency
7”7 s Air one seventeen can you zake the right

?..-I . . 2nd a left turn at Golf fcr ze please
.c. i‘ L,cIA.u
to hold short two two right
n-7 7.36
‘J.&A-r. i L’ s x : I, 7 S*Jre encugh ah we still have time tzl do that
7," Jc CLIL
T.'.. 3ne seventeen right at rr--'*q
iru*u Golf
short of tWG two right 'u' S Air one seventeen
C213:42
s-n,..
,ueer Xf f' *
i~~~ati*~*e S i' r reTLain cl.:
c.rr~ frequency
nc)*?.Ac
“b.L-I.*-I u s A 117 The windshear by the way was ah pretty
choppy started at a ataut seven hundred feet
-5 A G L we are getting ah fluctuations c f
0,
pli;S or YiTi-US ten all the way down to t!ie
growund
n-7 3. co
Vlj*-r..JU Tower 'Understand plus ;r zinus ten knots ah from
seven hundred feet to the surface 5y a 3 C
;i i ii e
I
cI1 A,
248
(0 *A.ea,
0 214 -.02 UC""7

Jr&-LA. 1 "I
rCah it was ah it was rcilgh dc*<n thrG*Ugh
tr'1 ere
0214:06 Tower Av e n s a f 1 v e twenty report ef windshear a plus
or miniis ah -- ten h-r;ots seven hundred feet
t. CLcrre surface report reported by a 3 C nine
0”
’II. 1 A n ,I
&A.%. A.-A ‘3" E520 OK Xvensa five two zero
A.17
0 2 1 %.A, L vrjer
mr. Clipper fo-ur seventy four a repcrt of
windshear -- gain or less of ten kROtS seven
hUEdred -- tG eL.
LLLe surface by a ah 3 C zinc
0214..A
"6 TGWSr XEleriCSil Six ninety two did ..a..
yvU cepy that
windshear
0214:29 AAL692 Affirmative
c)1 A. 3"
,n Tower
0 Yl't. OK
02:4:37 Tower Cligper four seventy foilr two two left wind
C ii e iii ii2 r zero at Giie illner c l e a r e d t o 1 an d
?. V R more than six thousand
Cleared to land Clipper four seveln foilr
Kennedy Tower Avianca zerc five twc heavy

established two two left
o21'*q
d.L 4 Tower Xvianca zerc five two heavy Kennedy Tower tWG
two left you're number three follcwing seven
two seven traffic on a ah -- niner mile
final
0215: 32 At‘A052 XViai*Ca zero five two heavy roger
o-1 E
&Ad:35 Tower Clipper four seventy fcur what's ycur
airspeed now
02:5:40 Tower &VU
American six ninety two traffic ahead c---r
miles is ene forty five now on the airspeed
r)9C.A5
0 &A-.* AAL692 Thank you
nc)q E. A 7 Avensa five two zero on Juliet

“Aid.tl AYE520
n-1 c
",&a:49 Tower Avensa five twenty ah taxi via J-uliet hold
sp,oi.t +..I
CW" two right and remain this frequency
ttC)lE.CA XVE520 Hold short cf two two right five two zero
‘-ldi&d.d*
q-1 E. EO
d&a.-. -” :: s A 1: 7 ?J s Air One seventeen holding short cf two
C*I" -.'
C.-r. r.L& at Golf
LAyALL
2216:OO Tower Affirmative sir hold short two two right
n-lc.Ag ‘J c *
3ne seventeen cross two two right
‘4 & A ” . t Tower Air
taGi right on the outer ground's on ene two

One point niner on the other side
V15:.6 ‘J s A 1 1 ? Cleared t.2 cross and twenty 2ne eighty nine

you say
3216:49 Tower X0 cne two one point niner
0216:51 USA117 I was going to say is that a new one

thanks a lot cleared across U S Air one
seventeen
2216:55 Tower American six ninety two two two left wind one
niner zero at two one cleared to land
AAL Cleared to land American six ninety two
0’
17. ‘! 0
.A” Tower Avianca zero five two what's your airspeed
0217-.20 43"V""52
AU Aviaiica zero five t-WG one four zero knots
250
Tower A V i a i* 2 a zer3 f;ve
' twa can you ,'..-..-,m,
&LILA ec(3c
airspeed ah Gne zerG knots
PLarL yo-u say again the speed
Tower Can you il?crease your airspeed 0 n e zeio

knots
Okay Gi‘e zero knots increasing
Tower Increase increase
1r;creasing
Tower Clipper four seventy four e..

c uiii r<.Ly- l-'
IL c,..;
c sL.%A Vi * a
Juliet hG:d short two two right and remain
this frequency
$218.“3
. YJ
F”“A7”
a-1 I t Clii;PSi fGui seven fsur rGger
3213 : 5c mvt* on9

LhrLUVi Kenned-y Tower T W A eight ZerG 2 ii e keavv ' 3
twelve point two Gil the C k: E
2:2:9:c!J Tawer TWA eight Gn one heavy Kennedy m----VIVVVCL roger

YG u're number three Gn the approach following
,\ e a vy seven oh Seven traffic ah four and a
half miles ahead you indicate ten knots
faster on the ground speed there
was a windshear report a loss of Gne a loss a
gain or loss of ten knots seven h-undred feet
TV the surface by a D C nine runway t-W-G tWG
left R V R more than six the-usand
02:9:19 TWA801 All right thank you sir
n-1
“*A..3 ..-rl
E7 Tower Avianca zero five t-WG t-do two left wind one
nine zerG at two zerG cleared to land
0220:02 X'y'XO52 Cleaied to land Avianca zero five c-ii0 heavy

1
251
3223304 XVAO52 Wind check please
n??n.nc
“G&“.“J Tower .3ne ,:,,
LLrrrtr zero at twc zero
0220:07 XVA052 Thank you
77n.,n
0 &rL". A." Tower Avianca zero five t-xc say airspeed
3223.7 3
.*.-I AVA052 Zero five two is ah 3ne ah fGUi five kilGtS
0220:16 Tower T W A eight oh one heavy if feasible reduce

airspeed one fo*ur five
T W A eight oh ciie heavy if feasible reduce

to your final approach speed at this tlxe
0 220356 TWA so: Y e s sir we're ir;dicatir;g one five zers ~iow
t I-iaL&I,3 about *l.
&,,e test we can do
022c-.53 Tower
n-i-3, . n-7
“&&A.” I Tclwer Avianca ZeiO f i 7 e two heavy Caii you increase
your airspeed Giie ZeiG knots at all
CI?, .'1? Yeah ah thanks

0 4AYI.i~ Tawer
0 221:30 Tower T W A eight oh one you're gaining on the

heavy seven oh seveii turn left heading of ah
-- one five zero and rr,aintain ah -- two
thlousand
f-l--,
V&&i:38 mr so
,A,“01 Okay T ": A eight sh Cne heavy a left t,o me
five zero Tialiltair; two thousand
252
3221:49 Tower Avianca zerG five two CiGSS two two right
taxi straight ahead now --- correction taxi
right ah -- right Gn the outer ground Gne two
one point niner
( n-i-t-\
“AD&,
"1".02
0 *&&. ZFK Xvensa
3222 -- 02 Tower Cerrection Avensa five ti;enty cross two two

right taxi right on the outer ground point
il in e
3222:06 AVE523 fioss tW0 t-W0 right right Gn tke a*uter and
sne twe 3iie pcint niner five two zerG
C)C)-t.,A.-sA F”““7A
3 &O&w axA-2 I c) Seven four cleared to cross
nn-?.,6
"IYC,. * Tower T '$ A eight oh one COiltaCt approach one Gne
eight FGiiit four
2222:21 TTJ* on9

cIU”.L Eighteen f GUi T 'd A eight oh one
n?cl7 -30
“Y&l6L:&U AXL692 Juliet short zf two two right American SiX
ninety two
on*-.
Y&*.32 hAL40 Tower American forty heavy's wit?, yGu Gutside
LGrrs
-c)c).') 6
0 .a&&.4 Tower American forty heavy Kennedy Tower rcger
runway two two left -- yoil’re number two
following heavy seven oh seven traffic on a
three mile final uind two zerG zerc at Oiie
eight R V R fi-ve thousand five hundred -- and
you're cleared to land
0222: 51 AALl0 Cleared to land American forty heavy

253
n9-i-i.c
v4l*Ll. 4 6 To-we r American forty heavy what's yGur airspeed
0 r173.no
&LlJ.” XXLlO Ah si,e sixty American forty teavy
nq-37 .n3
"IYdr"3 Tower Roger can yo-u ah increase it me zero knots
Affirm
I api;reciate that
AVAO 52 Executing a missed approach Avianca zero five

e..-
LW" l.&,eavy
C A.'I'-*-
*I..” and maintain one ah twa thousand one
eight zero Gn the heading
022?:55 TGWei %" right Charlie we're working ah

a*A
01”“.
d&-A.”n0 Tower X..J --I*
A%“A.QLILQ
0
3 in a right turn
r..: e--e
A” AQLLLCI zeic LZ..r.
A..L”C C..l
L.nv w.1..
Y"U
Ire zakir;g the left
a..--
Z-U& ‘I correct Sir
-78 .n7I xvnnc9

t%“d-L”-ILi rnLw.4.
LLL0L t 3 iigllt t o c n e e i g h t zers in t h e
0 &s**.v
heading and ah we'll try Gnce again we're
,..,,i
A. UI.‘. .I. -**g out ef fue 1
0224:13 Tower Okay
Ckay we got Avianca on the missed
0"" A
&A-:16 Tower Yes I’ve got
Pl
,AiZting to two Gne eighty zero ah
254
TOWei American ferty heavy Run-day !--<G t?<G left bii* n d
two zero zers at one niner cleared ts land
windshear repcrt a gain or lass of ten knots
s e v e n hundred feet to the surface ty a 3 C
nine
American forty
n-r..
+vrtei I got it
Tower Ckay
TGWei Avianca zero c: . . two heavy continue the left

Arve
turn headii,g Giie s: I. ZeiG .,,icL*LLL.cLLL;
Lrve ...; ,a.,: - two
5hGusand
:'"'A 052 3ne five zero maintaining two thousand

Avianca zero five
' l ...
Lmv h e a -q -
nc)*A. 3
“Lo&*.-I- 3 Tower Avianca zero five two heavy contact approach
bn Gne sne eight F;Oiiit four
nqCIA.A7
“L&t .% I Tower hi* d yau gut the windshear ever here
me*r-u Cl.-&
rvnc‘. G o t CLLP L
n-9A.c7
V&G%. -IA Tcwer Twenty c..-
Ln" left you own twenty two right
telGZgS to Sam on twenty three nine final in
-- and he's holding short sf Juliet right
O?“A.CO
OLI.r” Tower That's ccriect
2224359 ELY842 Tower SLAL eight four two good evening
3225: 3: Tower Okay thanks I got it

255
n--c
"Y&J:33 TGWei ELAL eight forty two heavy Kennedy TGwer
caution wake turbulence heavy E C ten seven
miles ahead wind two zerG zerG at Gne niner
runway two tWG left R V R more than six
the-usand cleared te land
0 225:12 ELYeC2 Cleared to land ELXL eight four two two two
left
0225:13 Tower ELXL eight forty t-w0 heavy ah plus minus ten
knots reported from seven !iundred feet to
surface ah ty a Z C nine
0225 .&I
- -3’ E7Y&U
,fO 42 Thank y-au copy
nr57c.3,
.J.s*.J. Jd Tower American six ninety two roger
022 5:37 Tower American six ninety two cross iUTiWaj; twG two
right at Juliet taxi straight ahead on the
inner advise clear of runway two two right on
CL *
cr*iS frequency
0226:11 XAL 692 American six ninety two is a -- clear Gf two

two right
0226:44 Tower American six ninety two taxi via the inner
monitor grG-und peint niner good night
0226:4? hAL692 Night now
Kennedy Tower its American fGur heavy at

thirteen Gut two two left
256
0 -7-7
o&I:59 Tower American four heavy Kennedy Tower a gain and
lGSS of ten knots reported at seven h-undred
feet tz, the s-urface by a D C nine wind two
zero zero at one niner run-way two two left
R V R more than six thousand cleared to Iand
0228:13 ..I A
asLY w Roger the shear and the winds for American
four heavy we’re cleared to land American
four heavy
0 228:17 Xl, 4tJ

laau Ah ah tower American forty the ah shear is
here and it's quite rough in the shear also,
plus or minus ten knots
0228325 mr..
Av,Ner American _=crt-y heavy roger four h-Gndred feet
Tower ELAL eight forty two heavy plus or min.us ten

knots reported by a heavy D C ten at four
hundred feet right now
0228:33 ELYS 4 2 Thank you
0225:33 Tower American fs-ur heavy plus or minus ten knots

reported by company heavy D C ten at this
time four hundred feet there is a:sc a heavy
hoeing seven forty seven ahead five miles
caution wake turbulence
And I ccpy ftr American four heavy
0229::s AALO What's the speed on the seven four in front

of American four heavy
0229:15 Tower American four heavy speeds comparable he's

six miles ahead no factor
Roger
257
Tower American forty heavy if able turn right at
first intersection Zuliet YGld short of
runway two two right remain this frequency
.
0229-49 XXL40 OK ah we're turning right here at juliet and
LLlGld short of two two right American forty
heavy
0229.=7
.d EIA102 Tower Evergreen one oh two heavy is a mile
Gut for two two left
0229:59 Tower Evergreen one oh two heavy Kennedy Tower

caution wake t-urbulence heavy D C ten six
miles ahead runway two two left R V R more
than six thousand wind two zero zero at one
eight plus or min.us ten knots reported at
four hundred feet by a heavy 3 C ten also
other reported at plus or rr.inus ten knots
frcm seven hundred feet to the surface by a D
C nine you're cleared to land runway two two
left
10230)
023 0:18 EIAlO2 Roger and cleared to land Evergreen one oh

two heavy
0230:50 Tower American forty heavy cross runway two two

right Juliet taxi straight ahead via the
inner advise clear of runway twa two right on
this frequency
0230:53 ML40 Cleared to cross two two right and ah

straight across on the inner and ah call
clear american forty heavy
.
0231-05 Tower Wind two zerG zero at one eight
0231-50
. TWA801 Kennedy Tower T W A eight zero one heavy is
with you again ah we're seventeen out
o-91
&.JA:55 Tower T W A eight oh one heavy Kennedy Tower
caution wake turbulence six miles in trail of
a heavy toeing seven forty seven runway two
two left R V R more than six thousand wind
two zero zero at one niner
258
(0 232 1
-33.03
0 *a*. TWA801 Roger eight zero one heavy thank you
0232:06 AALQO Forty heavy's clear of two two right
0232:07 Tower American forty heavy taxi via the inner

monitor ground point niner good day
0 232:lO AAL OK via the inner monitor ground point nine

thank you good night
Tower ELAL eight forty two heavy if able turn right

first intersection Juliet, hold short of
0232:19 ELYS42 Eight four two
0999.
*-I*.*-1 Tower And T W A eight oh one heavy plus minus one
zero knots reported from seven hundred feet
to the surface by a D C nine and then again
at four hundred feet by a heavy D C ten a few
minutes ago
0232:29 TWA801 T W A eight oh one thank you
(0233 1
0 233:04 Tower American four heavy say your airspeed
0 233 :12 Tower American fourSheavy say airspeed
0 233:14 AALQ Ah one fifty three
0233:16 Tower Ah ah evergreen one oh two heavy say your

airspeed
0233:18 EIA102 One seven zero
0233:20 Tower Ah ah evergreen one oh two heavy if practical

reduce speed to one five zero
I
259
Ah roger
ELAL eight forty two heavy crsss runway two

two right at Juliet taxi straight ahead via
the inner
advise tn this frequency when clear of runway
two two right
n-73.cn
“Odd.J” ELYS42 ELXL eight four two copy
(0234:
0234:27 ELY842 Tower eight four two two two right is

clear
. . CL *
.n93n.
VLJt. 30 Tower ELAL eight forty two heavy taxi via crre inner
and monitor ground point niner
0 234 :?4 ELY842 (Unintelligible) Thank you
( 0235 1
0235:25 NYT Departure
CI1E.96
0 8L-I-I.A Tower Yeah
nq?c.CIe
"Od-I.6 XYT Stop departures
02?5:27 Tower X11 departures stopped
0235:25 NYT LD
0 235:40 Tower American four heavy if able turn right first

intersection Juliet hold short runway two two
right remain this frequency
0 235:45 AAL Roger sir we're on ah juliet we'll hold

short
02?5:54 AAL And for American four a little bit of

turbulence at a thousand feet, you do get the
ah ten knot rise and the sink at about ah
five hundred feet
260
02?6:30 Tower American foilr heavy say again
. J
0236-O' AAL (Unintelligible) a little bit of turbulence
at a thousand feet then you get the ten knot
increase and the decrease just about f *i V e
h*undred feet
0236:O 9 Tower That's moderate turbulence
0236::: It's light
0236:12 Evergreen One ah two heavy mod light

turbulence One thousand feet plus or minus
ten knots at four hundred feet reported by
arrival heavy D C ten you're cleared to land
.a..-.--..
I Ullrrca~ two t-GO left runway two TWO left R t' R
scre cL LrraiL six thousand wind two zero
zero at one niner
2236:24 EIA132 Rc;ger evergreen ah ene oh two heavy
023 6:29 Tower T W A eight oh cne heavy --- light turbulence

Oil2 thoi;sand feet reported by a heavy 3 C
ten plus or z-in-us ten knots repcrted at four
hundred feet by the same D C ten cleared to
land r'unway t-we two left runway ~WG two left
R V R mere than six thousand wind two zere
zero at 3 r.2 riin e r
0 236:43 TWA801 Roger T W X eight zero One heavy
927,
(0 IcIJl,
0237:02 Tower American four heavy cross runway two two

right at Jtlliet taxi straight ahead on the
inner advise on this frequency clear of two
two right
0237.'7
.A Tower American four heavy cross two two right
juliet straight ahead on the inner advise
clear of two two right this frequency
0 237:25 me...
Awwer American fzlur heavy Kennedy TIswer
(0238)
261
EXXlO2 And for evargreen ah one oh two heavy's

clearing at jt;liet
0238:20 Tower Evergreen dne oh twe heavy hold short of

runway two two right juliat remain this
fraquency
0238:27 EIhl02 Roger
Cl-Jo..37
0 Ad” ML688 Ah Kennedy Tower American six eight eight
n?20
“*a”:39 Tower American six eighty eight heavy tower
023S:ll XAL6SS Yes sir ah you got the R 'J R for two two
'I .-.C4.c
LSA
0 CI?O.A4
4l-rU.3 mrrr
rvwer Runway two two left more than six thousand
0238:45 Thank you
0238:58 T W X eight oh one heavy 's the outer marker
0239:OO T W X eight oh one heavy Kennedy tzlwer wind

two zero zero at one niner cleared to land
0233:0? Cleared to land eight oh 6ne
0239:C6 Touer Evergreen dne oh two heavy say your

destination on the field
0239::o EIA102 Ah eastern ramp
0239::2 Tower Ah evergreen one oh two heavy what's your

position now sir
EC192 We're ah taxiing down Juliet
Tower You're cn Juliet right now
EIAlO2 That's affirmative

262
023.3:22 Tower Evergreen one oh two heavy cross runway two

two right at juliet y'o*u're in sight now m
the ah ground radar cross runway two twzl
right jilllet taxi via the iczer advise clear
two two right this f iYSgUeilCy
0239:23 ED.102 Ah roger we'll do ah evergreen one oh two

heavy
End of transcript
263
0210 UTC to January 26. 1990, 0243 UTC.
Auencies Makina Transmissions Abbreviation
New York TRACON NYT
Kennedy Tower Assistant Local Control JFK
Kennedy Tower Local Control Tower
Avianca Airlines Flight 052 AVA052
American Airlines Flight 692 ML692
American Airlines Flight 40 ML40
Avensa Airlines Flight 520 AVE520
USAir Airlines Flight 117 USA117
Trans World Airlines Flight 801 TWA801
National Weather Service Nws
EL AL-Israel Airlines Flight 842 ELY842
Evergreen Airlines Flight 102 EIAlO2
Transmissions from an unknown source UNK

accident:
Program Specialist
(0210)
(0211)
264
(0212)
(0213)
(0214)
0214:36 NYT Yes
0214:37 JFK Windshear new and improved
0214:38 NYT Windshear OK
0214:41 JFK Plus or minus ten knots - - - seven hundred

and below - - - D C nine
0214:48 NYT Ah seven hundred and below
0214:49 JFK YuP
0214:50 NYT OK thank you
0214:51 JFK Right A 0
0214:51 NYT J O
(0215)
0215:27 Tower seven two seven traffic on a
0215:32 AVA052 Avianca zero five two heavy roger
0215:35 Tower Clipper four seventy four what's your

airspeed now
0215:38 PAA One four five
0215:40 Tower American six ninety two traffic ahead four

miles is one forty five now on the airspeed
0215:45 AAL Thank you

266
0217:36 AVA052 Can you say again the speed
0217:37 Tower Can you increase your airspeed one zero

knots
0217:40 AVA052 Okay one zero knots increasing
0217:42 Tower Increase increase
0217:44 AVA052 Increasing
0217:45 Tower Alright
0218:18 Tower Clipper four seventy four turn right taxi via
Juliet hold short two two right and remain
this frequency
0218:23 PAA Clipper four seven four roger
0218:56 TWA801 Kennedy Tower T W A eight zero one heavy's

twelve point two on the D M E
0219:Ol Tower T W A eight oh one heavy Kennedy Tower roger

you're number three on the approach following
heavy seven oh seven traffic ah four and a
half miles ahead you indicate ten knots
faster on the ground speed there was a
windshear report a loss of one a loss a gain
or loss of ten knots seven hundred feet to
the surface by a D C nine Runway two two
left R V R more than six thousand
0219:19 TWA801 Alright thank you sir
0219:57 Tower Avianca zero five two two two left wind one
nine zero at two zero cleared to land
(0220)
022O:Ol AVA052 Cleared to land Avianca zero five two heavy
0220:04 AVA052 Wind check please

,E:43
32’ TCW 2::
1 XaS jGii&j t3 say iS that a >ew cne thar;ks a

lot cleared across U S Air 2iie seventeen
American six zir.ety t-rio t'*;o twc left wind t n e

iiiirer terc at t-n'= 2rne cleared t3 land
C1earc.d tc 1x9 Xmerizarr six ziiiety tii3
XViaiiCafern f i .. e two can you increase

iirsgeed a2 trre zero !;zi~ts
267
022O:OS Tower One nine zero at two zero
0220:07 AVA052 Thank you
022O:lO Tower Avianca zero five two say airspeed
0220:13 AVA052 Zero five two is ah one ah four five knots

airspeed one four five
0220:20 TWA801 OK we'll do our best

to your final approach speed at this time
0220:56 TWA801 Yes sir we're indicating one five zero now
That's about the best we can do
0220: 59 Tower Alright
(0221)
0221:ll NYT One said‘ yes
0221:12 JFK Hello there I think this A W ah T W A eight

oh one's gonna come out Avianca must be
putting his feet out the window
0221:18 NYT OK ah if you have to one ah fifty heading and

two thousand back to eighteen four
0221:23 JFK One fifty two thousand eighteen four thank

YOU
0221:25 NYT J O
0223:19 JPK Yes weather
0223320 NWS Yor Tower could I have a viribility chock

pleare
268
0223:22 JFK Todd get a vis check
0223:26 JFK Quarter mile
0223:27 NWS Still one quarter
0223:28 JFK That's "it
0223:29 NWS OK thank you very much
0223:29 JFK Alright
0223:30 NWS Bye bye
0223:46 JFK Does he have anybody rolling
0223:48 UNK Negative
0223:53 JFK Yeah
0223:54 JFK Yeah
0224:05 NYT Yes
0224:07 JFK Avianca's missing
0224:08 NYT OK
0224:08 JFK Due to the weather thing
0224:lO O K
0224:ll I'll give you one eighty at two speak to who
0224:12 OK one fifty at two if you can and one and ah

go to eighteen four with him
0224:14 (Intelligible)
269
0224:17 JFK Eighteen point four. thank you
0224:18 NYT JO
0224:53 Tower Sam on twenty three nine final in -- and he's

holding short of Juliet right
0224:58 Tower That's correct
0224:59 ELY842 Tower ELAL eight four two good evening

(unintelligible)
0225:OO Tower No that's it
0225:Ol Tower OK thanks I got it
0225:03 Tower ELAL eight forty two,heavy Kennedy Tower

caution wake turbulence heavy D C ten seven
miles ahead wind two zero zero at one niner
runway two two left R V R more than six
thousand cleared to land
0225:12 ELY842 Cleared to land ELAL eight four two two two
left
0225:14 Tower ELAL eight forty two heavy ah plus minus ten
knots reported from seven hundred feet to
surface ah by a D C nine
0225:21 ELY842 Thank you copy
0225:30 AAL American six ninety two short of two two

right at Juliet
0225:33 Tower American six ninety two roger
0225:37 Tower American six ninety two cross runway two two
this frequency
0225:43 AAL Six ninety two

270
q-e- . c= .., .
--- .“ ” .I .-. A. t
Ah ah Truer American ferty the ah shear is

here ar;d It’s quite rough iz the s.‘;ear Ei:.St
i;lUS Cr ZiilUS i 23 ki&GtS
Arieriean f= rty heavy roger fatlr hundred feet
n-c)0
“C&U:28 Tower ELAL eight forty two heavy plus cr .zini; s ten
knots reperted Sy a heavy 2 t ten at f3ur
hundre2 feet right n 3 w
1
271
0228:34 Tower American four heavy plus or minus ten knots
reported by company heavy D C ten at this
time four hundred feet there is also a heavy
Boeing seven forty seven ahead five miles
caution wake turbulence
0228:42 AAL And I copy for American four heavy
(0229)
0229:lS AAL What's the speed on the seven four in front

of American four heavy
0229:18 Tower American four heavy speeds comparable he's

six miles ahead no factor
0229:21 AAL Roger
0229:42 JFK Tower Cab
0229: 43 NYT Yeah Avianca fifty two says he can't go

around so we'll give him plenty of room
0229: 47 JFK OK thanks
0229:48 NYT JO
0229:48 JFK Bye bye
0229:49 NYT JO
(0230)
0230:02 Tower D C ten six miles ahead. Runway two two left
R V R more than six thousand wind two zero
zero at one eight plus or minus ten knots
reported at four hundred feet by a heavy D C
ten also other reported at plus or minus ten
knots from seven hundred feet to the surface
by a D C nine you're cleared to land runway
two two left
0230:18 EIAlO2 Roger and cleared to land Evergreen one oh

two heavy
272
023O:SO Tower American forty heavy cross runway two two
right Juliet taxi straight ahead via the
this frequency
0230:57 ML40 Cleared to cross two two right and ah

straight across on the inner and ah call
clear American forty heavy
(02311
0231:OS Tower Wind two zero zero at one eight
0231:50 TWA801 Kennedy Tower T W A eight zero one heavy is

with you again ah we're seventeen out
0231:55 Tower T W A eight oh one heavy Kennedy Tower

caution wake turbulence six miles in trail of
heavy boeing seven forty seven runway two
two left R V R more than six thousand wind
two zero zero at one.niner
(0232)
0232:03 TWA801 Roger eight zero one heavy thank you
0232:06 AALIO Forty heavy's clear of two two right
0232:07 Tower American forty heavy taxi via the inner,

monitor ground point niner good day
0232:lO AAL 40 OK via the inner monitor ground point nine

thank you good night
0232:13 Tower ELAL eight forty two heavy if able turn right
firrt intersection Juliet, hold short of
0232:19 ELY842 Eight four two
0232:21 Tower And T W A eight oh one heavy plus minus one

zero knots reported from seven hundred feet
to the surface by a D C nine and then again
at four hundred feet by a heavy D C ten a few
minutes ago
273
0232: 29 TWA801 T W A eight oh one thank you
0232:54 Unknown Ah let's see did you know ROBINSVILLE

DIXIE's and WHITE's are released
(0233)
0233:15 JFK Tower crab
0233:16 NYT Yeah Avianca fifty two lost an engine and

we're trying to find out why and get the
personnel and fuel
0233:21 JFK OK thank you
0233:22 NYT JO
(0234)
0234:17 JFK Tower Cab
0234:17 NYT Yeah we're not talking to Avianca any longer

he's fifteen northeast of Kennedy
0234:21 JFK Uh hum
0234:22 NYT OK so ah if you get him ah he's NORDO We

don't know what his altitude what his problem
was he last reported losing an engine
0234:28 JFK Oh wonderful
0234:28 NYT OK
0234:29 JFK Thank you
0234:30 NYT. J O
0234:30 JFK A0
I I
(0235) 274
0235:07 JFK Tower crab
0235:08 NYT We lost radar contact fifteen northeast of

Kennedy with Avianca
0235:ll JFK Thank you
0235:12 NYT JO
(0236)
(02371
0237:02 Tower American four heavy.cross runway two two

inner advise on this frequency clear of two
two right
0237:17 Tower American four heavy cross two two right

Juliet straight ahead on the inner advise
clear of two two right this frequency
0237:25 Tower American four heavy Kennedy Tower
(0238)
0238:06 Tower Alright Jim you checked your status

information areas the airport conditions
we’re I F R no runway taxiway closures no
windrhear uh actually there ir wind8hoar plu8
or ninur ten knot8 reven hundred below by a D
C nine at four hundred feet by a he8vp D C
ton no bird l dVi8Or ie8 br8king 8ction no
l dver8e ah action l quipnent 8tatur i8 all
normal no 8pecial coordin8tion8 ah
frequencier are 8tandard we're on taxii we
hmve 801110 8preq8 8ome rtop8 I believe which
are all ah relea8ed no other than normal
restriction8 we have eight minutes in trail
BO8tOn no altitude rertrictionr at thir tine
that I know of no 8peci81 8ctivitier except
for AVi8nC8 weather'8 I ? A the only unu8ual
ir you know Avimca and the traffic i8 all
being worked by local the only guy h8'8 got
on the fraqumcy T W A eight oh one heavy
inbound for two two left
I 1
275
(0239)
0239:02 Tower Check got it

. 0239:02 Tower Thank you
End of transcript
I I
276
APPENDIX E
SURFACE WEATHER OBSERVATIONS
10. Weather observations.
The following are the clouds, visibility, weather and wind from the
surface observations at John F. Kennedy International Airport during the
period from 0700 to 2200, January 25, and at Boston-Logan, Philadelphia,
Baltimore-Washington, and Hancock (Syracuse, NY) International Airports
for the period from 1900 to 2200, January 25.
The following are the clouds, visibility, weather, and wind from
the surface observations at John F. Kennedy International Airport during
the period from 0700 to 2200, January 25.
0650, surface aviation, ceiling measured 300 feet overcast,

visibility 2-l/2 miles in light rain and fog, wind 150 degrees
6 knots.
0753, record special, ceiling measured 400 feet overcast,

visibility 1 mile in moderate rain and fog, wind 120 degrees 7
knots, Runway 4R visual range 5,500 feet variable 6,000 feet,
surface visibility 2 miles, ceiling variable 300 to 500 feet.
0839, special, ceiling measured 300 feet overcast, visibility

l-3/4 miles in light rain and fog, wind 110 degrees 5 knots.

visibility l-3/4 miles in light rain and fog, wind 110 degrees
5 knots.

8 knots, light rain occasionally moderate rain.
1031, special, ceiling measured 300 feet broken 2,000 feet

overcast, visibility 2 miles in light rain and fog, wind 160
degrees 12 knots, surface visibility 2-l/2 miles.
1050, surface aviation, ceiling measured 300 feet broken 2,000

feet overcast, visibility 2 miles in light rain and fog, wind
140 degrees 8 knots, surface visibility 3 miles, 300 feet
broken variable scattered, pressure falling rapidly.

visibility 2 miles in moderate rain and fog, wind 160 degrees 9
knots, surface visibility 2-l/2 miles. D
277
1.211, special, ceiling measured 300 feet overcast, visibility

l/2 mile in light rain and fog, wind 140 degrees 8 knots,
Runway 4R visual range 6,000 feet plus, surface visibility 2
miles, pressure falling rapidly.

l-1/2 miles in light rain and fog, wind 140 degrees 10 knots,
surface visibility 2 miles, light rain occasionally moderate
rain.

8 knots, surface visibility 2 miles.

6 knots, surface visibility 3 miles, light rain occasionally
moderate rain.

2-l/2 miles in light rain and fog, wind 110 degrees 7 knots,
surface visibility 4 miles.

visibility 2-l/2 miles in light rain and fog, wind 110 degrees
8 knots, surface visibility 4 miles, precipitation very light.
1515, special, ceiling measured 300 feet overcast, vis;~;:l;~

2-l/2 miles in fog, wind 130 degrees 9 knots,
visibility 3 miles, wind variable 110 to 170 degrees.

1 mile in fog, wind 140 degrees 10 knots, Runway 4R visual
range 5,000 feet variable 6,000 feet, surface visibility l-1/2
miles, ceiling ragged.
1544, special, partial obscuration ceiling measured 300 feet

overcast, visibility l/2 mile in fog, wind 140 degrees 11
fog obscuring l/10 sky, surface visibility 3/4 mile, ceiling
ragged.
1553, record special, partial obscuration ceiling measured 200

feet overcast, visibility l/4 mile in fog, wind 140 degrees.10
fog obscuring 3/10 sky, rain ended 1456.
1650, surface aviation, partial obscuration ceiling measured

200 feet overcast, visibility l/4 mile in fog, wind 130
degrees 8 knots, Runway 4R visual range 2-,800 feet variable
4,000 feet, fog obscuring l/10 sky, surface visibility 1 mile.
278

200 feet overcast, visibility l/4 mile in fog, wind 130
degrees 8 knots, Runway 4R visual range 3,500 feet variable
6yiO feet, fog obscuring S/10 sky, surface visibility l/2
.
1850, record special, ceiling indefinite 200 feet obscured,

visibility l/4 mile in light drizzle and fog, wind 170 degrees
11 knots, Runway 4R visual range 1,800 feet variable 2,000
feet, drizzle began 1840.
1950, surface aviation, ceiling indefinite 200 feet obscured,

feet.
2024, special, ceiling indefinite 200 feet obscured,

feet.
2042, special, ceiling fndefinfte 200 feet obscured,

22 knots gusting to 28 knots, Runway 4R visual range 1,800
feet variable 2,200 feet.

visibility l/4 mile in light drizzle and 200 feet obscured,
20 knots gusting to 28 knots, Runway 4R visual range 1,800
feet variable 2,200 feet.

feet.
2135, special, partial obscuration ceiling measured 300 feet

overcast, visibility 3/4 mile in fog, wind 190 degrees 20
knots, Runway 4R visual range 5,500 feet variable 6,000 feet
plus, fog obscuring 3/10 sky.

300 feet overcast, visibility 3/4 mile in fog, wind 200
degrees 21 knots, Runway 4R visual range 5,500 feet variable
6,000 feet plus.
The following are the clouds, visibility, weather and wind from the
surface observations at Boston Logan International Airport,
Massachusetts, during the period from 1900 to 2200, clanuary 25.

visibility l/4 mile in light rain and fog, wind 030 degrees 7
knots, Runway 4R visual range 1,400 feet variable 2,400 feet.
279

knots, Runway 4R visual range 1,000 feet variable 1,400 feet.

feet, rain ended drizzle began 1945.

feet.

feet.

feet, surface visibility l/2 mile.
the surface observations at the Philadelphia, Pennsylvania,
International Airport during the period from 1900 to 2200, January 25.
1850, surface aviation, partial obscuration, ceiling measured

300 feet overcast, visibility l-1/4 miles in fog, wind 140
degrees 7 knots, fog obscuring S/10 sky.

2 miles in fog, wind 150 degrees 10 knots.
1917, special, ceiling measured 700 feet broken, 4,000 feet

overcast, visibility 3 miles in fog, wind 160 degrees 10
knots.
1950, record special, 700 feet scattered, ceiling estimated

4,000 feet overcast, visibility 5 miles in fog, wind 240
degrees 13 knots.

overcast, visibility 4 miles in light rain showers and fog,
wind 270 degrees 20 knots gusting to 25 knots.

overcast, visibility 2-l/2 miles in light rain showers and
fog * wind 240 degrees 12 knots gusting to 20 knots,
thunderstorm began 2008 west and north moving northeast,
occasional lightning in clouds.
280
2021, special, 700 feet scattered, 2,300 feet scattered,

ceiling estimated 4,000 feet overcast, visibility l-1/2 miles
in moderate rain showers and fog, wind 210 degrees 10 knots,
:;u;i;;;torrn northeast moving northeast, occasional lightning
.
2041, special, 1,200 feet scattered, ceiling estimated 4,000

feet overcast, visibility 2-l/2 miles in light rain showers
and fog, wind 200 degrees 10 knots, thunderstorms moved
northeast.
2050, special, 1,200 feet scattered, ceilfng estfmated 4,000

feet overcast, visibility 2-l/2 miles in light rain showers
and fog, wind 170 degrees 10 knots, thunderstorm began 2008,
ended 2038, moved northeast, rain began 1953. (This
observation should have been labeled surface aviation vice
special.)
2116, special, 800 feet scattered, 1,500 feet scattered,

ceiling estimated 4,000 feet overcast, visibility 5 miles in
light rain shower and fog, wind 180 degrees 10 knots.
2150, surface aviation, 800 feet scattered, ceiling estimated

4,500 feet overcast, visibility 5 miles in light rain showers
and fog, wind 180 degrees 16 knots.
the surface observations at the Baltimore-Washington International
Airport, Maryland, during the period from 1900 to 2200, January 25.
1850, surface aviation, ceiling measured 8,000 feet overcast,

knots, Runway 10 visual range 6,000 feet plus.
1930, special, 5,000 feet scattered ceiling measured 10,000

feet overcast, visibility 4 miles in light rain and fog, wind
170 degrees 6 knots.
1950, surface aviation, 600 feet scattered ceiling measured

10,000 feet overcast, visibility 7 miles in light rain, wind
180 degrees 9 knots.
2050, surface aviation, ceiling measured 8,000 feet overcast,

visibility 10 miles in light rain, wind 190 degrees 8 knots.
2150, record special, ceiling measured 1,800 feet overcast,

visibility 8 miles in light rain, wind 180 degrees 9 knots.
281
the surface observations from Hancock International Airport, Syracuse,
New York, during the period from 1900 to 2200, January 25.
1850, surface aviation, ceiling measured 1,900 feet broken,

2,800 feet overcast, visibility 10 miles, wind 130 degrees 10
knots, breaks in overcast.
1951, surface aviation, ceiling measured 2,000 feet broken

3,000 feet broken 4,500 feet overcast, visibility 10 miles,
wind 100 degrees 10 knots, breaks in overcast.
2053, surface aviation, ceiling measured 2,300 feet broken

wind 100 degrees 7 knots.
2151, record special, 2,300 feet scattered ceiling estimated

wind 230 degrees 9 knots.
1
282
APPENDIX F
COMMENTS ON DRAFT REPORT FROM THE ADMINISTRATIVE DEPARTMENT

OF CIVIL AERONAUTICS, COLOMBIA
REPUBLICA DE COLOMBIA
Departamento Administrative d e Ac: .;-. ., :. Civil
Bogota, 9th April 1991.
To : RONALD L. SHCLEEDE
CHIEF, MAJOR INVESTIGATIONS
NTSB WASHINGTON
FAX 202-382 6576
FROM :MAYORJORGE ENRIQUE LEAL
CHIEF,FLIGHT SAFETY DIVISION
ADMINISTRATIVE DEPARTAMENT OF CIVIL AVIATION
FAX 4138091
-ACOLOMBIA
REF : CONSIDERATIONS TO THE ACCIDENT INVESTIGATION REPORT DRAFT OF
AVIANCA FLIGHT 052 AT COVE NECK, NEW YORK ON JANUARY 25, 1990.
The Administrative Departament Of Civil Aerondutics (D.A.A.C.) in
representation of the government of Colombia would like to submit to
the consideration of the honorable members of the national
transportation safety board the inclusion of the following wints here
stated in tht final report of the accident investigation involving
Avianca flight 052.
This petition is requestid in accordance whith the protocol of the
International Civil Aviation Organization contained in its Annex 13 as
the State of Registry of the aiercraft involved in the accident. The
chief of Flight Safety Division of DAAC, as the Colombia acredited
tried to analize the entire report in the very short time you gave us.
It would be better if we had the 60 days ICAO~recomends to the State of
Registry of the aircraft.
CONMENTS.-
lo.- THE THIRD ITEM IN THE PARAGRAPH UNDER PROBABLE CAUSE WICH
ADDRESSES THE UsgElF OF INADEQUATE TRAFFIC MANAGEMMT a THE PART OF THE
F.A.A. SHOULD ALSO INCLUDE THE INADEQUATE HANDLING OF THE FLIGHT
ITSELF.
283
The actions and omissions on the part of ate that sustains such
allegation include :
The acceptance of flight 052 by the New York tracon under the repeated
insistence of New York A.R.T.C.C. was unsafe and misleading to the
flight crew. Consider that the conditions (weather and traffic) at
JFK should have been known by the controller before accepting an
aircraft he had no place for. If the controller had rejected the
Hand-Off,the crew of Avianca 052 wwd have been confronted with a less
ambiguous situation that would have demanded an alternative cause of
action. If in fact the Hand-Off was made beca~ of the request for
priority the subsequent handling of the flight was incorrect. The N.Y.
tracon is an airspace that contqlates no airborne holdings within it
and flight crews expect no delays once the are inside . The "SPIN"
given to AV052 was in fact a racetrack holding pattern (see Radar
Track) and presented an unannounced delay to the flight after a
priority request from the flight crew was made and they declared that
they were running out of fuel and could not make their alternate.
The Air Traffic Control Service rendered by the Control Tower at JFK
did IX& include mandatory information that should have been given to
the flight and in fact was given to every other aircraft that landed
prior to AV052. This information concerning runway visual range and
pireps of wind shear could have aided the pilot in his evaluation of
the conditions present during his approach. in addition, the control
tower gave no'special meaning to the statement made by the flight crew
"And we are running out fuel sir" madeduring theirmissedaproach.
20.0 THE -ATIONS OF THE REKIRT SHODLD w THE
MODIFICATION OF THE WAY THE AIR TRAFFIC -L SYST&¶ m TRE
ANTICIPATED DELAYS TO FLIGHT -. THE - EKPEcT RwllRfER
CLEARANCE TIME IXXS NUT. PROVIDE APILUIWHEZ4HECANEKP~TOLANDAND
THUSSERVESLITTLEPUReOSEINCCNTEMPLATINGTHEENTIREDELAYS&NARIO.
30.- TRE FEDERAL AVIATION REGULATIONS SHOULD REQDIRE AN ACTIVE FLI-
FOLIXIWING SYSTEM To ASSIST FLIGHT CREWS IN EVALUATING -
CONDITIONS AND TRAFFIC DELAYS AT THEIR INIZNDED ANDAL-
DESTINATIONS FOR INTERNATIONAL FLIGHTS WHICH AREt'KXTSUBJECTTOG
HOLDSAWDARENOTCONSIDEREDDIRECTLYINTHECENTRALFIXlW-
FACILITY PROGRAM.
284
bogotk~, D . E . 36-111
A b r i l 8 d e I.991
FAX
F'ARA : SeAor
RONALD L. SCHLEEDE
JEFE INVESTIGACIONES MAYURES
NAT I ONAL TRANSPORT AT I UN SAFETY BUARD
WASHINGTON D.C.
202- 9826376
DE : MAYOR JORGE ENRIRUE LEAL C.

JEFE DIVISION SEGURIDAD AEREA DAAC COLOMBIA
F A X 413-8091 B O G O T A D . E . - COLUMBIA
HEF : CONSIDEHACIDNES SOERE INFOKME ACCIPENTE AVIANCA (1) 5’2

EN NEW YORK. -
A p r e c i a d o seZor:
El D e p a r t a m e n t o Administrative d e l a AeronAutica Civil IDAAC) en

representacih-3 de1 G o b i e r n o d e Ccllombia, desea presentar a l a
consideracihn d e las H o n o r a b l e s M i e m b r o s d e l a J u n t a d e Seguridad
National de1 T r a n s p o r t e , l a incluido e n 10s s i g u i e n t e s punt.c:rs en
relacih c o n el i n f orme final sob-e l a investigacitin de1
accidente d e A V I A N C A e n su vuelo i)52.-
Esta apreciacihn s e t-lace d e a c u e r d o c o n l o estipulada en ei

protocol0 d e l a Organizacihn d e Aviacibn C i v i l (OACl) comu pai
de r e q i s t r o d e l a a e r o n a v e i m p l i c a d a e n e l accidente.-
La Divisih d e S e g u r i d a d A&red. coma representante acredi. tado

para 9sta investigaci6n, llevt a cabo el anAlisis con,;~leto de 1
informe, n o obstante el r e d u c i d u t i e m p o d i s p u n i b l e Ye acuerdu a
SLI solicited; 10s pre5en tes comen tarir35 z podrian haber side LI 1’1
poco m&s prof undos; ir de i-:aberse contado con 10s &lt:> dias q L! e
recomienda el A~;F,:o 13 de la OACI.-
COMENTARIOS
PHcl~AP,_E
1. E L TEPCER P U N T 0 D E L PAHAGKAFO R E S P E C T 0 A L A CAL&A
EN EL CUAL SE MENCIONA EL MANEJO INADECUADO DEL ‘TRAFICO l-‘l:)K
P A R - I - E D E L A F . A . A . DEEEREA SEB M A S ESPECIFICO, MENC I ONANDO
AL VUELO 052, E L C U A L E S M O T I V O D E E S T A INVESTIGACION.-
La5 ac tuac iones y omisianes por par t.e de I control de

trAfic0 a&reo q u e rjostienen ec.ta afirmaclbn incluyen:
L a aceptacibn de1 Vuelo 052 par- el c o n t r o l termina I d e r a d a r

de aproximacihn d e N e w York: ( N e w York ~Tracon 1 y ante 1a
r e p e t i d a i n s i s t e n c i a de1 Centro d e C o n t r o l d e Tr-.$flcct k 9 r e c,
d e N e w Y o r k (ARTCC N e w YnrK) 3 fu& Insegur-a, ocasiw~ando C!I’~ a
posible confusihn a la tripulacitin de vuelo. 5. e c C-J I') c.. j, c.j p r ;'I
que la5 condiclones ( Atmosf&ri.ic:as v ‘I- r-h f 1. i.: o ) +zr i k.i’ 1

285
; (.,’:c c’i i .+. . . .:i..
I ,;.. i-. .e, ,;-,
dftberian
I ;”‘t. p r r’; ~~1 ;z 1. y:; y.; +z, ,L haber
di:G-lt~ r: . t:::EI\IflJE;p‘V’ ,
5:. .j. cl (3 I:: 0 1-12 c.. I d a 5 par e 1 Con trrn 1 adczr antes de aceptar otra
a.ey'gT'i&k,@ pars, l a cual r-in t e n i a e s p a c i o . S i e l Controlador se
hu.b;.era negado y l a tripulac~.~n d e l a Aeronave d e AVlANCA5 e n
55 iJ ‘2’ 11 e 1 il3 r:t 52 i se h a b r i a e n c o n t r a d o a n t e una situaci6r1 menos
am b I g 1-t a ‘, 10 qL\e hubiera requerido un cut-50 de accibn
a :! t e r ri 0 . S.I. d e hechop ia aceptacibn d e manejar l a aeronave 3
5e 1. l evC:l a cabo debido a l a exigencia d e priorldad p ei
subsecuente manei 0 dei vctelo fete incorrecto. El Cuntrc_l
‘T’ermifia 1 de 1 Radar de Aproximacirkt de New York:: (New Y 0 r 1::
‘Trac:ofi ) f es 1.t n espac io here0 que n o cuntempla el
sost.enimiento e n v u e l o , p a r l o cctal, l a s tripulaciones de
v~telcr:1 nc! ec,peran demora5 una Vei se encuentran dentro.-
E1 Cirr.uito ordenado a la aeronave de1 vuelo 052, de hec ho

f lie LIT1 patrbn d e e s p e r a (Ver Graf ica de1 Radar- ir 3
presrntando!3e ctna d e m o r a n o anunci.ada para e l vuela, aespu&s
de Cl Ll e 1a trlpulacibn d e v u e l o requi rib prioridad y
d e c 1 araron que se estaban quedandc, sin combustible y clue n0
p D C:l i 43 I-7 a%c::anzar el a e r o p u e r t o a l terno.-
El servicio dada por e.i Control de ‘Tr&fico A&reu en l a T o r r - e

de Ct3ntrc!l de1 aeropuerto lfOHN F. KENNEDY 9 no inclctyb 1a
rnfur-mac.xbn mandat.Dria de1 case, que d e b e r i a h a b e r s i d o d a d a
a1 vuelo c:t s 2 ~ y de hec ho 9 si fue d a d a a todas la5 utras
a p r 0 1-1 a i: e ~2._ que aterrlzar-on antec. de1 vuelo 052 de AV I ANCA .
E5ti irifc3rmac:itrr; c,e relaciona con el rang0 visual de pista y
reportes de Pi 1 otos sobre car tan tes de vient.0, 10 ccral
habria ayctdadc> a l Pilota e n SLI evaluacibn d e las c o n d n c i o n e s
presenter duran tc 5u aproximac i.& . Adem&s b la Torre de
C o n t r o l nu di.b e s p e c i a l siqnlficado a l o manxfestado p o r la
tripulacic3n cuando di.jeron d u r a n t e SLI aproximaci& frustrada
: II mm* no5 estamus quedando s i n c o m b u s t i b l e , se6or”.
LAS &;Ej-J’jMENL){~(-; 1 (-jNE:S DEL f NF’C\RME DEBEK I AN EST I MULAR LA

MODI F I C::AC::I. UN DE I-A MANERA E N OUE E L S I S T E M A A C T U A L DE
C:C::il\ij ROL -~RAF 1 cc;) AEREO i A-rc j PRESENTA LAS DEMORAS POR
ANTICIF’AD:E A LA TR I P!JLAC I ON DE VUEL-0. E L I-ERMINO
(‘:;CjF;‘RI EN2-E DE “HUHA P R E V I S T A D E AUTORIZACION” z NO 1NDIC:A AL
FVLOT’O CLJANDO F’UEDE E S P E R A R A’TERRI ZAR Y SIRVE D E POCK E N E L
AkLISIS D E L ESCENARTO G E N E R A L D E DEMORAS.-
LAS FIEW.JL.AC:IONES DE L.A AVIACION FEDERAL DEBERIAN HEOUERIR UN

s I :< T’Eygj AC:-f 1 V,c) DE SEGUI MI ENTO DE VUELO f PARA AYUDAR A LA
TRI F’i.JL...AC I ON A EVAL~lJAR tAS COND ICI CINES ATMOSFER I CAS Y DEMURAS
EN El.... ?-RAF J: CC) EN SUS AEROPUERTOS DE DES-r INO Y ALTERNOS PAHA
OUF'L." _ ns
.- IN T’ERNAC :[ ONAL-ES y L O S ClJALES N O E S T A N SUJETOS A SER
rwau-m I ~tx2 E N TIERRA Y N D SON CUNSIDERADOS DIRECTAMENTE E N
El- “PROGRAMA DE FACI LI TACI ON DEL CONTROL CENTRAL DE FLUJ0” . -
Gteri tamer-~ te ,
:~~~~a~j' A~rea
* U . S . G.P.0.:1991-281~626:20054
I
/.’
/3
’

Aar91 04 PDF

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Aar91 04 PDF

Uploaded by

Copyright:

Available Formats

/ \

AIRCRAFT ACCIDENT REPORT

National Transportation Safety Board

AIRCRAFT ACCIDENT REPORT

AVIANCA, THE AIRLINE OF COLUMBIA

ADOPTED: APRIL 30,199l

On July 19, 1989, at approximately 2134 eastern standard time,

Because of poor weather conditions in the northeastern part of the

The National Transportation Safety Board determines that the

The safety issues raised in this report include:

1. Pilot responsibilities and dispatch responsibilities

2. Pilot to controller communications regarding the

3. ATC flow control procedures and responsibilities to

4. Flightcrew coordination and English language proficiency

AIRCRAFT ACCIDENT REPORT

AVIANCA, THE AIRLINE OF COLOMBIA

1.1 History of the Flight

On Thursday, January 25, 1990, at approximately 2134 eastern

AVA052 departed Bogota International Airport at 1310, 5 minutes

’U n l e s s otherwise indicated, all times shown are eastern standard

3 Flight Level is a level of constant atmospheric pressure related to a

AVA052 entered the airspace of Miami Air Route Traffic Control

As the flight proceeded northward, it was placed in holding three

Between the ORF and CAMRN intersections, AVA052 was cleared to

..* Recorded by FAA:

BEGIN .=. 7 1 - Captain, 2 - First Officer, 3 - Flight Engineer

Figure 1. --AVA052 flight reconstruction based on CVR, ATC radar

Time (H,M,S) Selected Diaglogue

(Continued on next page)

Time (H,M,S) Selected Diaglogue

43) 21,23,37 CAM3 - Smooth with the nose . . .

A handoff controller, who was assisting the radar controller at the

After being advised by the handoff controller that the NY TRACON

At 2047:21, the first officer contacted the NY TRACON feeder

AVA052 was then provided with routine radar service, including

At 2056:16, the feeder controller advised, "Avianca zero five two

’ “Spin you” i s a n o n s t a n d a r d t e r m t h a t r e f e r s t o m a k i n g a 360’ t u r n .

At 2102:39, AVA052 was instructed to contact the NY TRACON final

At 2103:46, the flightcrew began to discuss the procedure for

At 2108:34, AVA052 was instructed to descend to 3,000 feet. The

The following intracockpit conversations in Spanish (recorded on

At 2111:07, the final controller stated, "...you are one five

At 2111:16 (CVR), the captain said, "select the ILS on my side."

Figure 2.--Jeppesen Approach Plate of ILS to runway 22 left at JFK.

At 2115:19, the first officer contacted JFK Tower, stating that

At 2117:17, JFK tower controller inquired, "Avianca zero five two

At 2120:17 (CVR), the captain said, "give me fifty," and at

At 2121:41 (CVR), the captain said, "localizer glideslope one

At 2122:57 (CVR), the first officer said, "this is the windshear."

At 2123:34, the first officer radioed, "executing a missed

At 2123:54 (CVR), the captain said, "flaps twenty five." The

At 2124:04, JFK tower controller stated, "Avianca zero five two

Note: Limits correspond to full

3.00 3.50 4.00 6.00 7.00

Distance - Nautical Miles

Figure 3. --AVA052 ILS approach--profile view.

At 2124:32, JFK tower instructed, "Avianca zero five two heavy

At 2124:55 (CVR), the captain said, "flaps fifteen." Then, also at

At 2125:08 (CVR), the captain said, "advise him we don't have

At 2126:27, the NY TRACON final controller instructed, "Avianca

At 2130:55 (CVR), the captain said, "set flaps fourteen." The

At 2131:01, the NY TRACON controller stated, "okay and you're