NTSB – DC-9 – Virgin Islands – May 2, 1970. Adopted March 31, 1971. (SA-420 - File B-0001).
The National Transportation Safety Board determines that the probable cause of this accident was fuel exhaustion which resulted from continued, unsuccessful attempts to land at St. Maarten until insufficient fuel remained to reach alternate airport.
The Board also finds that the probability of survival would have been increased substantially in this accident if there had been better crew coordination prior to and during the ditching.
The Board has recommended that actions be taken to improve passenger safety through adequate warning, proper briefing, standardized seatbelts, and more accessible stowage of lifevests for emergencies.
Finally, the Board recommends that the FAA reassess the standards pertaining to certification of flotation equipment used aboard aircraft.
Then all three cabin attendants assisted individual passengers as necessary. Some could not remove the lifevests from the pouch under the seat, and others were unable to don the vest properly. The navigator was sent back to the cabin to assist with preparations for ditching, and he helped the purser move the 25-man raft from the forward coat closet, on the left side of the aircraft, to the galley area directly opposite on the right side.
Although none of the five 25-man rafts on board the aircraft was deployed, several rafts were air-dropped at the ditching site.
While the fuel management procedures that were used are demonstrably incompatible with the flight plan procedures, a detailed discussion of the en route procedures is somewhat academic, since the total estimated time to fuel exhaustion of 4 hours 34 minutes compares with remarkable accuracy to the actual fuel exhaustion time of 4 hours 35 minutes.
It is, therefore, the to the last 1 hour of flight that attention must the be directed.
Of particular interest are the events, which followed the captain's initial decision to divert to San Juan, after being advised that St. Maarten weather conditions had gone below the approved minimums. If the flight had proceeded average to San Juan, the accident obviously would not would have happened. Of interest, then, are the reasons for altering this decision, and the return to the course for St. Maarten.
8. Notwithstanding any instrument indications of fuel quantity, the captain should have realized that he was at or near minimum fuel for successful diversion to his alternate, and should have employed the most efficient means of reaching that alternate. This included the use of emergency authority.
9. The cabin attendants did not fully appreciate the gravity of the situation. They were not given signals to warn that ditching was imminent and to brace for impact, which then could have been relayed to the passengers.
The Safety Board further recommends that: The FAA reassess the standards set forth in FAR, parts 37.122 and 37.178 pertaining to the certification of liferafts and lifevests, with a view toward eliminating the deficiencies in such equipment as evidenced by the investigative record of this accident.
Research and development should be undertaken, as necessary, to accomplish this reassessment and improvement of standards. The evidence established in this investigation indicates that additional deficiencies in survival procedures and survival equipment may exist.
Because of this evidence, the Safety Board has in progress the writing of a special report concerning the study of passenger survival in this and other accidents. It is anticipated that this study will yield further recommendations concerning passenger survival.
(My bold and spacing).
Toward the end of the report, openly published is the dialogue between the NTSB and the FAA, great stuff. No secret squirrel emails for these boys (well maybe a bit), but the report was produced in less than a year and did not need a Senate enquiry....Ah, the old days eh.
(Can't help the 'syntax' it's hard to lift the paragraphs from the report).