Out of Balance: The crash of Fine Air flight 101
On the 7th of August 1997, a routine cargo flight carrying a load of denim to the Dominican Republic failed to become airborne on takeoff from Miami. The Douglas DC-8 pitched up, stalled, and crashed to the ground in the parking lot of a mini-mall, killing all four people on board as well as one on the ground. At first, the fiery crash appeared to be a classic case of shifting cargo, a problem that has long plagued the air freight industry. But the cause proved to be more complex — and more sinister. Diving into the sequence of events leading up to the accident, investigators unraveled a chain of miscommunications and reckless decisions that put the plane’s center of gravity too far to the rear, and discovered that Fine Air and its contractor Aeromar had been trying to hide the truth from the eyes of the NTSB.
Fine Air was a cargo airline based out of Miami International Airport, from which it first flew scheduled services in 1994. Founded by businessman J. Frank Fine, the airline transported raw materials and other goods between South Florida and various destinations in Latin America using a fleet of antiquated Douglas DC-8s and a Lockheed L-1011 Tristar. Fine Air quickly became the largest of the many cargo airlines operating out of Miami, and in 1997, under the leadership of Fine’s son Barry, the airline entered the stock market as a publicly traded company. At its IPO on the 6th of August, investors sank $123.3 million into Fine Air — a decision they would come to regret within hours.
The following day, Fine Air was scheduled to carry a load of 40,000 kilograms of raw denim to Santo Domingo, capital of the Dominican Republic, on behalf of the Dominican freight forwarding company Aeromar (with whom Fine Air had signed a wet lease agreement). The shipment of denim arrived at Fine Air’s loading dock at Miami International Airport sometime after 3:00 in the morning, at which point Aeromar planned to load it onto a Fine Air DC-8 scheduled to leave at 9:31. But there was a problem right out of the gate: the plane that was supposed to operate the flight had been delayed. At the request of Aeromar, Fine Air flew in another DC-8 from Puerto Rico to replace it.
Meanwhile, Aeromar personnel weighed the cargo and a Fine Air “flight follower” (for the purposes of this article, the same thing as a dispatcher), used this information to assemble a weight and balance load sheet for the flight. Because every airplane has a maximum allowable takeoff weight and must have a carefully balanced center of gravity, this information is important to ensure that the plane can get airborne. The center of gravity, the point at which the plane would theoretically balance if you held it up on your fingertip, needs to be within a certain distance of the centerline of the wings. The position of the center of gravity (CG) is measured as a percentage of the mean aerodynamic chord (MAC), or the average width of the wing, based on its distance from the forward end of the MAC. So a center of gravity located 30% of the way along the MAC in an aft direction is denoted as an “Aft CG of 30% MAC.” On the DC-8, the aft CG limit, or the furthest allowable aft position of the center of gravity, was 33.1% MAC. If the center of gravity was further aft than this, the plane could pitch up uncontrollably on takeoff.
The Fine Air flight follower who prepared the load sheet initially based his calculations on the DC-8 that had originally been scheduled to perform the flight. He gave the load sheet to the Aeromar security guard in charge of the shipment, then learned some time later that the aircraft had been changed. Minor variations in the aircraft configuration meant that this plane weighed slightly more empty than did the original, and to keep it under the maximum allowable takeoff weight, 454 kilograms of cargo would need to be removed. The flight follower called an Aeromar security guard (who was not in charge of this shipment) and asked that the cargo be removed. The security guard called his supervisor, who told him to remove the weight from the balance sheet, and that he would order the actual removal of the cargo when he got to work. Apparently this never happened. Although the extra weight was struck off the load sheet, it was not removed from the plane.
However, that wasn’t the only problem with the aircraft’s weight. The Fine Air flight follower, in his calculations, did not account for the fact that Aeromar’s measurement of the cargo weight didn’t include the pallets or netting. This would have added nearly 2,000 kilograms to the weight of the shipment. The combination of this mistake and the failure to remove the extra cargo meant that the plane exceeded its maximum allowable takeoff weight by approximately 2,400 kilograms.
Later that morning, an Aeromar loading team, assisted by a Fine Air load supervisor, set about loading the 16 pallets of cargo onto the plane. The DC-8 had 18 cargo pallet positions, numbered from front to back, and the load sheet called for positions 2 and 17 to be left empty. The loading team slid the pallets into place along tracks in the floor, starting at the back of the plane and working their way forward. However, they ran into a problem with pallets 3, 4, and 5. On these pallets, cargo spilled over the edges, preventing them from locking into place in their respective positions on the floor track. After debating how to resolve the problem, the loading team apparently devised a new plan. They removed pallets 3 and 4 from the plane, then pushed pallets 5 through 16 back one space, occupying the previously empty position 17. Then pallet 4 was rotated 90 degrees and placed in position 5, extending partially into position 4. It was tied down independently of the other pallets and the pallet track. Finally, they returned pallet 3 to its original position. As a result of this rearrangement, positions 2 and 4 were empty instead of positions 2 and 17, meaning that the load, which was already excessively heavy, had also been shifted toward the rear of the plane. This changed the center of gravity from 30% MAC, as indicated on the load sheet, to at least 32.8% MAC, approaching the DC-8’s aft CG limit of 33.1%.
After all the cargo was loaded and secured, the flight crew arrived to fly the plane to Santo Domingo. Four people boarded the plane: Captain Dale Thompson, First Officer Steven Petrosky, Flight Engineer Glen Millington, and the Aeromar security guard assigned to the shipment. The pilots received a copy of the load sheet, and flight engineer Millington conducted the pre-flight checks. Although he was supposed to check all of the cargo pallets, Fine Air’s loading practices often made it impossible to walk alongside the pallets in the cargo hold, so he never saw anything aft of position 3. The change in the positions of the pallets, which was not indicated on the load sheet, went undetected.
Pilots use the calculated center of gravity and gross weight to determine what flight control and engine power settings will be needed for takeoff. Before takeoff, pilots set (or “trim”) the horizontal stabilizer to a nose up position so that the plane “stabilizes” in a climb without the constant application of large control column pressures. The exact position of the stabilizer depends on the location of the aircraft’s center of gravity. A farther aft CG naturally produces a greater pitch up motion and reduces the amount of stabilizer trim necessary to achieve the desired climb angle. The load sheet indicated an aft CG of 30% MAC and a corresponding stabilizer trim setting of 2.4 units nose up. However, the actual CG of at least 32.8% MAC would have required a trim setting of no more than 0.9 units nose up. But the pilots didn’t know that the CG on the load sheet was wrong and pre-set the stabilizer trim to 2.4 units.
At 12:35 p.m., Fine Air flight 101 was cleared to take off from Miami International Airport’s runway 27R. All seemed normal as the DC-8 accelerated down the runway, until it came time to rotate the nose upward for liftoff. As soon as Captain Thompson called out “rotate” and First Officer Petrosky pulled back on his control column, the plane started pitching up much more steeply than expected. “Easy, easy, easy, easy,” Thompson said, prompting Petrosky to back off the controls for a second.
But the plane kept pitching up. “What’s going on?” Petrosky asked.
“Whoa,” said Thompson. Both pilots started trying to push the nose down, but it remained dangerously high. At that moment they appeared to realize that there was a problem with the trim setting, and Petrosky started frantically trying to adjust the trim nose down using the manual trim wheel on the cockpit center console. But it was already too late. At such a steep pitch angle, the plane lost speed rapidly and approached a stall. The stick shaker activated, warning of the impending stall, while the pilots fought to bring their dangerously off-kilter jet under control.
The DC-8 lurched past the end of the runway in a crazy nose-high attitude, flying less than 200 feet above the ground. The stick shaker stopped momentarily then immediately started again. “Oh no, fuck, no,” Thompson exclaimed. “Hold on, keep it light, easy, damn.”
The plane started to descend as it lost lift and stalled. An automated voice called out, “Too low, gear.”
“Oh shit,” Thompson said, as the ground proximity warning started to go off — “Too low, terrain! Terrain!” At that point the DC-8’s extreme angle of attack interrupted the smooth airflow into the engines, and engine number four started surging, sending bursts of flame out the exhaust pipe. A cacophony of bangs, terrain alarms, and cursing filled the cockpit.
“Something — what’s happening?” First Officer Petrosky shouted. There was no answer. The ground rose up to meet them with terrifying rapidity. Petrosky’s final exclamation, “Oh no,” was the last sound captured on the cockpit voice recorder.
At a nearby mini-mall specializing in hardware and electronics, shoppers and motorists spotted the plane coming and fled for their lives. With a nose-up pitch of 23 degrees and a 20-degree right bank, the DC-8 crashed tail-first into a field past the end of the runway. The fuselage slammed to the ground and slid forward for 160 meters, plowing across all six lanes of Northwest 72nd Avenue before coming to a stop in the parking lot of the mini-mall. The mangled wreckage exploded on impact, sending a massive fireball curling up over the commercial district in west Miami.
Emergency services, who arrived on the scene within two minutes, were faced with total chaos. People crowded the streets, wandering in shock as firefighters tackled the blaze and tried to prevent it from spreading to nearby buildings. Flames had engulfed the wreckage of the DC-8, as well as the remains of at least 12 cars in the parking lot, and the conflagration took 30 minutes to fully extinguish. Miraculously, no cars were driving along that stretch of Northwest 72nd Avenue at the moment of impact — by sheer coincidence, the lights at both ends of the block were red, leaving the street uncharacteristically empty.
Unfortunately, not everyone managed to escape. Emergency crews found that all four people on board the DC-8 were killed on impact, along with a customer of the mini-mall who was crushed to death inside his parked car. In addition to the deaths, property damage to the street, cars, and adjacent businesses totaled nearly $1 million.
Investigators with the National Transportation Safety Board arrived at the crash site within hours and set about trying to uncover the cause. However, a surprising discovery initially sent them down a line of inquiry that turned out to have nothing to do with why the plane crashed. The NTSB recovered 60 of the 85 “bear claw” locks that were meant to hold the pallets in place, and 57 of them appeared to have been unlocked at the time of the crash. This suggested that the cargo might not have been properly secured and could have shifted during the takeoff, causing the plane to pitch up steeply. But interviews with Aeromar personnel showed that this wasn’t the case: while it was true that most of the locks were left open, the locks on pallets 1, 3, and 18 — the only pallets that had space to slide back — were properly engaged. As it turned out, Aeromar cargo loaders didn’t seem to understand the importance of locking all of the cargo, and they only locked pallets 1 and 3 because the flight engineer could see them and would ask them to reload the cargo if he noticed they were unlocked. So, while the cargo couldn’t have shifted, it was clear that something was seriously wrong with the way Aeromar and Fine Air handled the loading process.
An analysis of the flight data and the load sheet showed that if the center of gravity, gross weight, and trim setting indicated on the sheet were correct, then the plane shouldn’t have had any trouble getting airborne. Looking into the pilots, the NTSB found that none were stellar airmen — they all had spotty records riddled with violations and shortcomings. But the cockpit voice recording showed beyond doubt that they followed the specified trim setting, and no evidence could be found that they did anything wrong.
Attention then turned to the load sheet itself. Over a series of interviews, major discrepancies began to emerge. A miscommunication meant that excess cargo removed from the load sheet was not actually taken off the plane. And an interview with an Aeromar vice president revealed that their weight measurement for the cargo didn’t include the pallets or packaging. New calculations showed that these errors left the plane significantly overweight. But that wasn’t enough to cause the crash by itself, as simulator testing showed that the plane could still take off normally even if it exceeded its max takeoff weight by 2,400 kilograms.
Security camera footage of the loading process finally provided the missing link. The video revealed critical details that the two load supervisors had withheld from the NTSB in their initial interviews. Now that the NTSB had the video, however, they spilled the beans. The Aeromar supervisor explained exactly how the cargo was moved backwards to make room for the pallet that was too large, and claimed that the Fine Air supervisor had ordered them to do this. The Fine Air supervisor denied this, stating that he never told anyone to move the pallets backwards, and that the Aeromar supervisor was responsible. The two supervisors, who had earlier tried to keep quiet, had now thrown each other under the bus. Although the security footage from the day of the crash showed the supervisors engaged in a heated argument, the video did not include sound, and the NTSB couldn’t determine who actually came up with the deadly plan. Calculations showed that it was indeed this change, in combination with the excess weight, that caused the plane to pitch up too steeply on takeoff.
While the NTSB investigated the crash, the Federal Aviation Administration scrutinized the wet lease agreement between Fine Air and Aeromar. To their surprise, the language of the contract showed that it wasn’t really a wet lease at all. The FAA found that Fine Air’s “wet leases” were in fact “transportation agreements (perhaps even ‘charters’) from Fine to various foreign carriers, or perhaps fixed price guarantees for certain possible cargo transportation services that Fine may be called upon to provide over the next couple of years.” In fact, Fine Air could not sign a true lease agreement with non-US companies like Aeromar that weren’t certified for operations under Part 121 of the Federal Aviation Regulations. As such, Fine Air was not allowed to sign over any part of its operations to Aeromar, including the cargo loading. By law, Fine Air should have been loading its planes, not Aeromar. And the agreement with Aeromar wasn’t Fine Air’s only sketchy wet lease with a non-US company — in fact, they made such agreements frequently. The FAA even turned up an instance in which Fine Air airplanes and pilots operated at least nine flights as “Air Jamaica” without signing any kind of formal lease agreement with Air Jamaica.
Digging deeper, the NTSB and FAA uncovered still more shocking facts about Fine Air. For example, in 1994, the airline submitted an application to transport cargo for the Department of Defense Air Mobility Command. The DoD rejected the application after a review of the airline found that its audit program was inadequate, its general operations manual was not current, its flight and duty time program was unsatisfactory, it had no crew resource management program, its HAZMAT training was inadequate, there were discrepancies in required flight documentation, and its management, training, scheduling, and operational control were all “below average.”
Furthermore, a review of the records of the accident airplane revealed numerous unaddressed mechanical problems, and scrutiny of its load sheet turned up several additional errors that had nothing to do with the crash. After the accident, an FAA inspection of Fine Air’s cargo loading practices uncovered a wide range of problems, including improperly secured pallets and cargo, as well as frayed cargo netting that had been repaired with a type of nylon rope not approved for use on aircraft. An FAA inspector found that on one of Fine Air’s DC-8s, the floor was literally disintegrating, with numerous holes and “soft spots” that buckled when weight was placed on them. Despite pointing out the problem, the inspector checked the same plane again later and found it hadn’t been fixed. It also did not appear that Fine Air exercised any operational control over the loading process at all. And three days before the crash, a pilot discovered a serious error in his airplane’s center of gravity calculation, forcing Fine Air to cancel the flight. The evidence kept adding up: something was seriously wrong with this airline.
On the 12th of September 1997, the FAA and Fine Air signed a “consent agreement” whereby Fine Air would halt all operations until it could prove compliance with a series of FAA ultimatums. As part of the consent agreement, Fine Air launched a program to give formal classroom training to its cargo loaders, including theoretical lessons about weight and balance. Fine Air also adopted a new form for load supervisors to follow with step-by-step instructions. Overhauls took place in numerous other areas as well, and the FAA allowed Fine Air to begin flying again on the 28th of October. But the damage had already been done. In 2000, Fine Air filed for chapter 11 bankruptcy, and it was eventually acquired by a private investment group that subsumed it into the charter airline Arrow Air. Arrow Air was itself liquidated in 2010, erasing the last trace of Fine Air.
However, the NTSB did not believe that the buck stopped with Fine Air. Investigators also had to ask why the FAA didn’t catch on to Fine Air’s constant violations until after the fatal accident. As with many other crashes, it eventually emerged that the FAA inspectors assigned to Fine Air simply didn’t have time to apply the necessary level of scrutiny. Too much of their time had to be devoted to routine certification tasks, and they lacked enough assistants to effectively monitor Fine Air’s operations for day-to-day compliance. On top of this, the FAA inspectors had little background knowledge about cargo loading and lacked any sort of guidance materials to help them evaluate it. As a result, cargo loading was never really on the inspectors’ radar. Describing his attitude before the crash, one FAA inspector said, “To us, cargo is cargo” — the implication being that cargo was unimportant. And this wasn’t the only time the FAA failed to uncover consistent violations at a US airline — just the previous year, the crash of ValuJet flight 592 was traced back to severe negligence at ValuJet’s Miami-based contractor, which the FAA did not discover. The NTSB stated that FAA officials didn’t seem capable of catching on to patterns of negligence, in part because inspectors felt that reporting violations entailed too much paperwork.
In its final report, the NTSB issued a large number of safety recommendations to prevent this sort of accident from happening again. These recommendations included that pilots be trained to quickly recognize and react to incorrect trim settings; that the FAA audit all cargo operators to ensure their compliance with weight and balance requirements; that load supervisors be given checklists to guide the loading process; that airlines provide formal training to cargo loaders, including instruction on the hazards of improper loading; that the FAA consider requiring technology that can measure and display weight and balance information to the pilots directly; that FAA inspectors provide oversight of cargo loading; that the FAA review its inspection programs to determine why it had failed to detect patterns of negligence; and that the FAA seek an increased oversight budget. Several additional recommendations pertained to problems found during the investigation, but which were not causal to the crash.
In recent years, the safety of cargo airlines in the United States has improved, but accidents continue to happen. While US passenger airlines haven’t had a major accident since 2009, cargo is a different story: in that same 10-year period, four large US cargo planes have crashed with the loss of all hands, including one due to bad cargo loading practices. Because these crashes don’t result in high death tolls, there is little public pressure for reform. Nevertheless, progress is being made, particularly as the FAA and NTSB continue the constant battle against the sprawling network of shady companies operating out of South Florida. In the years both before and after the Fine Air crash, several cargo airlines were shut down temporarily or permanently due to patterns of violations, including some that resulted in fatalities. But if cargo airlines are to be held to the same standard as passenger airlines, the FAA may need a larger budget than politicians are willing to give it.
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