Talk:United Air Lines Flight 389

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I corrected the time of impact, to one hour later, than previously indicated. I also added material which reflected on the most likely cause of this accident, even though there was not enough evidence to say with reasonable certainty.

--EditorASC 09:53, 24 July 2006 (UTC)

I added the alternate theory bacause I witnessed flight 389 explode mid air, break in half and fall into the water. Editor JJ 06:05, 13 Jan 2009 (UTC)

Should this alternate theory be set into a separate section on the page? The part, "This is a question that has seldom even been asked" seems especially problematic to include this theory. Not that I want to discount Editor JJ's account, but my understanding is that Wikipedia tries to rely on documented sources over personal observation. It also seems like it needs to be edited to fit the style of Wikipedia. Since I am not familiar with this incident, I'd rather leave that kind of change to someone who understands this category more.--jqubed (Talk | Contributions) 19:57, 14 January 2009 (UTC)

Almost all notable accidents are plagued with alternate kook theories by a small group (sometimes only one or two), that claim the cause was entirely different than that in the official accident report. There should be no place in Wikipedia for such theories, simply because there is no valid evidence to support them.

There was no evidence of the plane exploding before it hit the water. The fireball was created by the rupturing of the fuel tanks, after the plane impacted Lake Michigan. Almost 82% of the wreckage (by weight) was recovered, as well as all of the bodies. Nothing indicated an explosion before the fireball that erupted as the plane impacted the water. The nature of the wreckage clearly indicated that the plane hit the water with a slight nose up attitude, with the right wing just a bit lower than the left wing, which caused the plane to rotate to the right, upon impact.

It is very clear, from Radar tapes and time records, that the plane was down to 1,500 to 2,000 ft. MSL, during its last radio transmission. The pilots did not indicate any problem then, yet they had descended below their clearance limit of 6,000 ft. The only logical explanation, given all the physical evidence, is that the pilots misread their 3-point altimeters by 10,000 ft. EditorASC (talk) 00:56, 17 February 2009 (UTC)

Mel had very little time on the 727, the copilot had less than 400 hours. The copilot was flying. They had been flying the Viscount and DC-6/7 respectively. The 727 had far higher performance, pilots loved it. There was much speculation that they were simply descending at too high a rate and suffered spacial disorientation. The 727 was viewed as having fantastic performance and many felt it induced overconfidence. At no time in the descent from cruise had the aircraft flown level. The airplane averaged 2,000 FPM the whole descent. There was no doubt the aircraft was flown into the water slightly nose high and right wing slightly low. There were three other 727 accidents that involved CFIT in quick succession. AA, UAL, (Salt Lake City) and All Nippon. The latter was a mirror image of Flight 389.Mark Lincoln (talk) 18:04, 16 April 2010 (UTC)

While you came to the correct (logical) conclusion, I don't think "fantastic performance" or "far higher performance" had anything to do with it. When the pilot descends, after receiving that command from ATC, he does so by controlling his rate of descent according to how fast he thinks he needs to descend, to meet his objective. It matters not if he is using the autopilot to set the rate of descent (in this case, approx 2,000 FPM), or is hand flying. If he thinks that is the proper rate, to get the plane to the altitude he seeks, within the area he thinks is desirable (according to his estimate of how close he will be to the airport, when he reaches the commanded altitude), then he will descend at that rate, no matter what kind of plane he is flying. For instance, if the plane was say, 100 miles further out, when it received the command to descend to 6,000 ft., then he would have selected a descent rate that was considerably lower, than he did in this case. Pilots do math calculations in their head, to figure out the best descent rate in any given scenario. They figure out what their average ground speed is and at what point they should arrive at the specified altitude, and how many miles they will cover during that descent. From that they calculate what their descent rate should be, so as to have a smooth and consistent rate, which gives the passenger the smoothest flight possible.

The "performance" capability of the plane they are flying does not figure in that kind of calculation, so long as the necessary descent rate is within the performance envelope of that plane. A Viscount or a DC-6 can descend at 2,000 FPM, just as easily as a jetliner. Whether it would or not, given the same scenario as the accident flight, would depend on what kind of ground speed it would have, while carrying out that same ATC command, over the same flight path. Since jets are "cleaner," they tend to have more forward speed during a 2,000 FPM rate of descent, with all engines at idle thrust, than would a prop plane. If the prop plane needed more speed in the descent, than it would have with idle thrust, then the pilot will only partially retard the thrust levers. If the jet will have too much speed during an idle thrust descent, then they will use the speed brakes to slow it down. My point is that both the ground speed and the rate of descent is deliberate and calculated by the pilot, regardless of what kind of plane they are flying.

Of course, if the pilot had read the altimeter correctly, he would not have thought he still had another few thousand feet to descend, when he was already over 4,000 ft. below the assigned level-off altitude of 6,000 ft. That misreading of the altimeter obviously affected his rate-of-descent calculation. It is likely that he would have been descending at a lesser rate (probably in the 1,500 to 1,800 rate of descent range), if he had not tried to go down 10,000 ft. more.

As to spatial disorientation, I see no reason for that kind of speculation, especially since the plane was in the expected attitude of a plane in which the pilot thought he had a few more thousand feet to go down before leveling off. So long as the pilots' flight instruments are functioning properly, there is no reason to suspect spatial disorientation from a pilot that is fully qualified to fly via IFR rules. Spatial disorientation is not normally generated by the speed or descent rate of an aircraft, if the pilot is IFR qualified and flying according to IFR rules, as all airline pilots do. In the extremely rare cases, where airline pilots were thought to have been victims of spatial disorientation, it is almost always the result of one or more malfunctions of the necessary flight instruments. There was no evidence found in this accident investigation, that any necessary flight instruments had malfunctioned. The misreading of a 3-pointer altimeter (which in this case, made the pilot think the plane was 10,000 ft. higher than it actually was), is an interpretation error by the pilot, not a spatial disorientation error.

The moral of the story is that correct reading of the flight instruments is as important as the ability to fly the plane, solely by reference to those instruments. 66.81.53.192 (talk) 08:53, 12 September 2011 (UTC)

The 727 was involved in a number of approach accidents with the common theme of controlled flight into terrain over water or flat land. Once word got out the wave of accidents ended. Folks started paying attention. The transition from round engines to jets was breathtaking and required changes in training and attitude.

There was no indication of in-flight fire or explosion. The aircraft hit the water slightly nose up, and slightly right-wing low. They were configured for the descent. The aircraft was clearly in a stabile descent and under control. Some speculation in the accident report that having descended out of a layer of clouds about 8,000 feet the copilot may have simply misread the altitude. The board never did find a reason for their descent below 6,000 feet.Mark Lincoln (talk) 22:01, 13 September 2011 (UTC)

I am making the inference that these statements are trying to make a point, but the wording is a bit too imprecise for me to understand what that point might be:

The 727 was involved in a number of approach accidents with the common theme of controlled flight into terrain over water or flat land. Once word got out the wave of accidents ended. Folks started paying attention. The transition from round engines to jets was breathtaking and required changes in training and attitude.

I do not understand what you mean by "Once word got out the wave of accidents ended. Folks started paying attention." What word got out? Can you supply a citation source that might better explain what you are talking about? That might be helpful, if you can.

Cite a source? Well I don't have all the original pages from the 727 manual. Lots of them changed, old ones were discarded. How did word get around? The usual means, gossip, accident reports, changes in manuals and training.Mark Lincoln (talk) 20:15, 19 September 2011 (UTC)

Even more perplexing is this statement of "The transition from round engines to jets was breathtaking and required changes in training and attitude." The word "breathtaking" is not a normal aviation nomenclature expression, when trying to explain why any accident happened. And, what kind of "attitude" are you talking about, and who, specifically had that "attitude?" and what was it changed from and what was it changed too?

After guys had been flying in DC-6s (as the Flight 389 copilot had) or Viscounts (as Mel had) the performance of the 727 was exceptional. Going from an initial rate of climb of 1,000 or 1,300 fpm to over 2,000 was breathtaking. As were the cruising altitudes and speeds. The 'Jet Age' was still arriving. What kind of attitude? A lot of older pilots were disinclined to abandon proceeders which had served them well in the DC-3 or DC-6. This most often evidenced itself with the more senior Captains, but also with some younger pilots. The idea that a jet had to be flow 'by the book' and by the numbers was not always taken to heart. Training was intensified, and and made much more consistent. This was the results of efforts by the FAA, Airlines, and ALPAMark Lincoln (talk) 20:15, 19 September 2011 (UTC).

Are you making reference to these accidents:

United Airlines Flight 389, American Airlines Flight 383, United Airlines Flight 227, All Nippon Airways Flight 60?

and somehow implying that they all had the same cause? If so, can you be more specific than simply saying they were CFIT accidents, since that doesn't tell us WHY each happened? Thank you, 66.81.53.68 (talk) 20:24, 17 September 2011 (UTC)

The common threads were descent at night with deceptive visual clues, and the fact that the crew had the aircraft under control until impact. They did not have a single common cause. Rather they had a several common factors which required changes in how the 727 was flown. There was a degree of concern for a while that there was something fundamentally wrong with the airplane. That was untrue. It was not as 'forgiving' of inattention than say the DC-3 which most pilots of the time had started their airline careers flying.Mark Lincoln (talk) 20:15, 19 September 2011 (UTC)

BTW, the UAL SLC 727 crash was NOT a CFIT accident. To the contrary, it crashed because of the horrible judgment and actions of the captain, that led to loss of control. 66.81.52.104 (talk) 12:10, 19 September 2011 (UTC)

Kehmeier was known amongst copilots for his inability to cope with the changes in aircraft performance. He was known to not provide for spool-up time, and failure to stabilize approaches. I have dug up the accident report. Probable Cause 'The board determines the probable cause of this accident was the failure of the Captain to take timely action to arrest an excessive descent rate during the landing approach.' The Recommendations were "!. The Board is concerned that the procedures for pilot testing prevailing at the time of this accident were such that an individual with the pilot behavioral characteristics of the pilot in this case could qualify and be retained as pilot-in-command of a B-0727 aircraft. The Board therefore recommends that both the Federal Aviation Agency and the air carriers reexamine existing procedures to the end that all feasible steps maybe taken to make sure that airmen who serve as pilots-in-command of commercial aircraft, and in particular high-speed jet aircraft such as the B-727, possess not only the requisite technical skills, but the necessary qualities of prudence, judgement and care as well." The CAB had insufficient information to make a finding of probable cause in Mel Toule's crash and thus no recommendations could be made. In the AA Cincinnati case the drum style altimeter was considered as a factor, which many thought might have also applied to Mel's accident. Mark Lincoln (talk) 20:15, 19 September 2011 (UTC)

Might I ask, without causing affront, how old you are? Airline flying was very different 45 years ago.Mark Lincoln (talk) 20:15, 19 September 2011 (UTC)

==Citations Now Supplied==

I provided additional source footnotes, which support all statements about the accident sequence and theory about the cause. I then removed the lack of citations banner, which was at the beginning of the article. EditorASC (talk) 09:15, 11 April 2009 (UTC)

TPA-ORD-BOI

Could somebody please explain what a TPA-ORD-BOI is, as mentioned in the intro? Calistemon (talk) 16:00, 7 March 2011 (UTC)

Those are airport acronyms. TPA = Tampa, FL, ORD = Chicago, O'Hare, BOI = Boise, Idaho. It now shows DSM as the last stop. DSM = Des Moines, Iowa. Cheers! 66.81.53.192 (talk) 07:42, 12 September 2011 (UTC)

Interesting, but not relevant

Thank you for your additional comments. Although I may have some different conclusions, I now understand better what you were getting at.

In response to this statement:

"After guys had been flying in DC-6s (as the Flight 389 copilot had) or Viscounts (as Mel had) the performance of the 727 was exceptional. Going from an initial rate of climb of 1,000 or 1,300 fpm to over 2,000 was breathtaking. As were the cruising altitudes and speeds. The 'Jet Age' was still arriving."

True that the jets had a lot more climb and speed performance than the preceding prop airliners, but I don't see that as a contributing factor in the UAL 389 accident. Your phraseology might be creative and appropriate for a novel about airline pilots, but as incisive nomenclature that is useful and standard in accident analysis, it is both irrelevant & non-illuminating.

There was nothing unusual about the plane making a rather consistent and steady descent at an average rate of 2,000 FPM. Nothing unusual, until the pilot busted the assigned altitude of 6,000 ft. and was still descending at that rate, apparently without anyone in the cockpit being aware that they had descended below their clearance limit of 6,000 ft. It was a sound conclusion that they had a total lack of awareness of their immediate peril, after their last radio transmission was proved to have occurred while the plane was descending thru 2,000 to 500 ft. above the water. Either they all misread the two altimeters by 10,000 ft., or they got preoccupied with looking for the lights ahead, after they broke out of the overcast layer. Distraction flowing from erroneous interpretation of a critical flight instrument, or distraction by looking outside at the time that the plane went thru 6,000 ft. Maybe a combination of both, and also likely that the Black Hole illusion reinforced their lack of awareness of how low they really were.

What was similar about both the AMR and UAL-ORD accidents, is that they were approaching at night in marginal WX conditions (rapidly deteriorating, in the AMR case) -- a classic "black hole" environment. You probably are aware of the Boeing study many years ago, where they did a lot of simulator tests with pilots flying night, visual approaches over "black holes" that were devoid of adequate lighting cues, that would help the pilots judge the correct visual descent rate, without referencing their flight instruments.

Using a flight simulator, experienced Boeing instructor pilots (with more than 10,000 hours each) conducted entirely visual approaches to runways in black hole conditions. The result was that without the aid of altimeter or glide slope information, most pilots flew excessively low approaches and crashed into terrain short of the runway. [1]

What was NOT similar, was that the AMR flight was an IOE flight, with the check captain in the right seat. Additionally, they were in the final approach phase, with flaps extended only to 25 degrees. As they turned final, they still had not extended the landing gear, nor was the final descent check list done. They obviously, were getting "way behind the plane" at that point as they tried desperately to maintain visual contact with the airport runway, while the WX was deteriorating rapidly. The result was they failed to monitor their altimeters and VSIs, and the check captain failed to make the required call-outs too. As evidenced by a last radio transmission from the flight, just seconds before impact, they crashed below the elevation of the airport runway, because of work overload that proved such a giant distraction that they were not aware they were too low, The Black Hole illusion most likely contributed to their belief, that they were on a proper glide slope profile.

Their departure from LaGuardia was delayed by 20 minutes. They knew the WX was forecast to get worse at destination, so they were rushing to try and land before they might be forced to proceed to an alternate. Very similar situation in the AMR Little Rock accident, in 1999. Rushing has always proved to be a dangerous factor in any flight. A major factor in the TO crash of NWA at DTW, in 1987. Black hole environment, with rapidly deteriorating WX and a crew that was rushing to make the approach before the line of thunderstorms reached the airport. All those factors combined to create another tragic CFIT accident.

In both the AMR & UAL-ORD accidents, the pilots were deceived into thinking they were a lot higher than they really were, even though some of the causitive factors differed between those two accidents. That was not the case in the UAL-SLC accident.

You are quite correct about Kehmeier; he was one of those dangerous "reputation" captains, from much the same mold as the captain that ran the 727 off the runway when landing on 26L at DEN, after they pulled a lot of CBs, following a smell of smoke. Not to mention the turkey in command of Allegheny 485, that crashed into beach cottages on Long Island Sound in June, 1971. And, that was the point I was making: the SLC crash was not classified as one of the CFIT accidents, because it was a clear night and he tried to make the landing, from a position where the plane was too high and too close to the airport. He was supposed to ask for an extended vector to give him time to lose altitude in a safe manner, before conducting a visual approach. His slapping the hand back of the FO, when he had tried to increase thrust, was a deliberate act of gambling with the lives of all on board, just so he could avoid the embarrassment of having to miss the approach and go around for another try. Another one of those "testosterone" approaches, by a captain who valued saving face, more than he did protecting all the lives entrusted to him.

I do remember that those four 727 accidents (3 of which were classified as CFIT), caused a lot of flap in the press that came from the usual ignorant reporter types, who don't know an aileron from a trim tab, suggesting that there was some inherent defect in the 727 design. There wasn't of course, but when ignoramuses prattle on and find it gives them a claim to fame, they tend to milk it for all it is worth. The close proximity in time of those accidents, was the "red flag" for the ignorant reporters, but we all know that the same kinds of accidents, with similar contributing factors, have occurred repeatedly over the years with other types of jetliners. But since they were not grouped close together in time, they escaped the prattle of ignorant reporters.

As to the All Nippon that crashed in Tokyo Bay, I cannot comment on what led to that CFIT, since I have never been able to find an English translation of that accident report.

Thanks for taking the time to respond; I have enjoyed the additional enlightenment. 66.81.52.125 (talk) 09:52, 20 September 2011 (UTC)

There was a lot made of four crashes involving the 727. Much of it speculation in the non-technical press. In the question of ANA 60, there was no finding of probable cause. The aircraft impacted the water in a stabile descent and normal attitude.

The concern amongst pilots flying the 727 for United was that there might be something wrong, not with the airplane, but how it was being operated. Some deficiency in training or procedures. ANA 60 and Mel Toule's accident both involved a night approach over water. TWA also involved a night approach, with bad weather. That one was a total goat rope where everything that could be done wrong was. . . Still, coming on the heels of Mel's it did cause speculation, and not just in the press. The SLC crash was, contrary to normal usage, not referred to casually as 'Salt Lake City' as was common, for example 'Tell City' or "Parottsville," the accident was deemed 'Kehmeire." The accident was fodder for press speculation, but not in operations.

The gist of my position is in the AA 383 report on page 25. "Also, consideration must be given to the fact that the 727 does have highly responsive and versatile flight characteristics and that the favorable characteristics may be misleading to the pilot, or are presenting the impression that greater liberties may be taken with the aircraft in normal operating situations, especially in the approach/landing regimes."

After a sting of four night approach/landing accidents in a row in less than six months, changes in attitude, operating procedures and training eliminated such frequent accidents in 727s. By today's standards the 727 might be hum drum, perhaps even a dog with fleas, but when it was new and the folks moving up to it were coming out of DC-6s (like the copilot flying 389) it was a 'hot' even seductive airplane. Guys liked it. Still, as the guys horsing around in AA 383 proved, you couldn't fly unstabilized visual approaches in shitty weather no matter how many times you had pulled it off in a DC-6 (which was what the guy flying 383 had flown before the 727).

The 'string' of 727 approach/landing accidents was as important in adjusting training and attitude as the rash of 'Jet Upset" accidents in the early 1960s.Mark Lincoln (talk) 15:53, 20 September 2011 (UTC)

A number of CFIT accidents in other parts of the world were caused by misreading of the then-new three-hand altimeters such that these instruments were eventually discontinued. — Preceding unsigned comment added by 95.149.247.75 (talk) 13:34, 7 April 2019 (UTC)

Probable cause

"While the former carried only a flight crew, all seven passengers and two crew members perished in the latter accident, and survivors helped to pinpoint the cause."

This is confusing and ambiguous. PRL42 (talk) 18:15, 1 July 2012 (UTC)

Edit to infobox removing pilot error

The INFOBOX unequivocally stated "pilot error". While the article suggests that there may have been pilot error, the phrasing "it was believed that the crash was most likely the result of the pilots" is far too weak to support the unadulterated "pilot error" so I removed it. The article states "A definitive cause was not determined by National Transportation Safety Board (NTSB) investigators", so the INFOBOX entry was too strong.--S Philbrick(Talk) 16:14, 5 September 2017 (UTC)

Crash

I was there. I was 10 years old and staying on the shore of Lake Michigan at my Grandpa's Cottage. We were in Michigan approximately 6 - 7 miles North of South Haven and 1 mile South of Glenn. It seemed to be the flight pattern for most jets across the Lake to O'Hare or Midway in Chicago from the East Coast. I loved Airplanes so I watched them frequently. My grandpa had an old shortwave radio so I often listened to the radio communicatons from air to tower as well. I heard the pilot that night and saw the plane. I thought that it was way to low as it roared over. I could see the bottom of the plane!! We never saw the plane that close, nor could we hear one that loud! It was dark, but I could see it!! I yelled at grandpa that it was going to crash and about that time, just over the horizon a I heard a huge boom and enormous ball of fire lit up the night sky. I knew it crashed!! I made grandpa call the local police and tell them! Nobody would ever listen to me, however. Perhaps if they had, they would have known the aircraft was definitely flying way too low before it crashed. It would have helped their investigation! 2001:5B0:46E0:A7E8:1CA9:1250:94E2:F143 (talk) 14:38, 5 November 2022 (UTC)