ElAl Flight 1862

RAAD VOOR DE LUCHTVAART
Nederlands Aviation
Safety Boar d
AIRCRAFT ACCIDENT REPORT

92-1 1
EL AL FLIGHT 1862
BOEING 747-258F 4X-AXG
BIJLMERMEER, AMSTERDAM
OCTOBER 4, 1992
FINAL RAPPOR T
on the accident with EI Al 186 2
on October 4, 199 2
at Amsterdam - Bijlmermee r
1. INVESTIGATIO N
The Netherlands Aviation Safety Board was informed on th e
accident on that same day . On the recommendation of the Board ,
the Minister of Transport, Public Works and Watermanagemen t
nominated a Preliminary Investigator, mr . H .N . Wolleswinkel .
An investigation was conducted under his management, resultin g
in a Preliminary Report of Investigation which was presented t o
the Board on October 4, 1993 .
After having been informed on the first results of the investigation, the Board decided on June 28, 1993, to conduct a furthe r
investigation during a public hearing .
2. PUBLIC HEARIN G
The public hearing on this accident was held in the Netherland s
Congress Centre in The Hague, on October 14 and 15, 1993 .
The following sworn Experts/Witnesses presented their views t o
the Board :
mr . B .L . Eberhardt, mr . M .E . Lundberg, Captain W .F . Lorenz an d
mr . B . van Keppel from Boeing ;
mr . D . Finkelstein and Captain A . Oz from EI Al ;
Prof . A . Berkovits from Technion Israel Institute of Technology ;
mr . Th .E . McSweeny from FAA Washington ;
mr . C .W . van Santen and mr . B . Klaare from the Department o f
Civil Aviation ;
mr . J . van Veen, formerly of ATC ;
mr . S .S . Koopmans from ATC ;
mr . S .S . de Haan, mr . H .J . Copier and mr . H .J . van Lente of KLM .
The Board consisted of :
mr . G .W .M . Bodewes ; Chairman .
mr . J .P .H . Winkelman, mr . L .W . Snoek, mr . J . Hofstra ,
mr . E .R . Mller, mr . H .P . Corssmit, mr . J . Smit, mr . C . Barendregt
and mr . M . van der Veen : Members .
mr . J .M . Jansen : Acting Secretary .
3.
FINAL REPOR T
Following the public hearing the Netherlands Aviation Safet y
Board has issued this final report in the English language . A translated version in the Dutch language will be issued later .
Hoofddorp, February 24 1994 .
CONTEN S
SYNOPSI S
1 FACTUAL INFORMATION
History of the Fligh t
1 .1
Injuries to Person s
1 .2
1 .3
Damage to Aircraf t
1 .4
Other Damag e
Personnel Informatio n
1 .5
Aircraft Informatio n
1 .6
1 .6 .1
Genera l
Pylons, Fuse Pins and Nacelle Attach Fitting s
1 .6 .2
Aircraft Desig n
1 .6 .3
Pylon to Wing Attachment Desig n
1 .6 .3 .1
Hydraulic System s
1 .6 .3 .2
1 .6 .3 .3
Pneumatic Syste m
1 .6 .3 .4
Electrical Syste m
1 .6 .3 .5
Flight Control s
1 .6 .3 .6
Fuel Syste m
Engine Fire Detection and Extinguishing Syste m
1 .6 .3 .7
Service Bulletins and Airworthiness Directive s
1 .6 .4
Service Bulletins Applicable to Midspar Fuse Pin s
1 .6 .4 .1
Service Bulletins Applicable to Diagonal Brace Fuse Pin s
1 .6 .4 .2
1 .6 .4 .3
Service Bulletins Applicable to Attach Fitting s
1 .6 .4 .4
Service Bulletins Applicable to the Nacelle Strut Rea r
Engine Mount Bulkhea d
1 .7
Meteorological Informatio n
1 .7 .1
General Condition s
Conditions at the time of the Cras h
1 .7 .2
Aerodrome Traffic Information Service (ATIS )
1 .7 .3
1 .8
Aids to Navigatio n
Communications and Recording s
1 .9
1 .9 .1
ATC Communication Recording s
1 .9 .2
Other Communication Recording s
1 .9 .3
Radar Data Recording s
1 .10
Airport Informatio n
1 .11
Flight Recorder s
1 .11 .1
Digital Flight Data Recorde r
1 .11 .2
Cockpit Voice Recorde r
1 .12
Wreckage and Impact Informatio n
1 .12 .1
Impact Area of the Engines and Wing Component s
1 .12 .2
Main Impact Are a
1 .12 .3
Damage to Aircraft
1 .12 .3 .1 Damage to Right Wing Structur e
1 .12 .3 .2 Damage to Engine s
1 .12 .3 .3 Damage to Hydraulic System s
1 .12 .3 .4 Damage to Pneumatic Syste m
1 .12 .3 .5 Damage to Electrical Syste m
1 .12 .3 .6 Damage to Fuel Syste m
1 .12 .3 .7 Damage to Fire Detection and Extinguishing System s
1 .13
Medical and Pathological Informatio n
1 .14
Fire
1 .14 .1
Fire on Board
1 .14 .2
Fire on the Groun d
1 .14 .3
Fire Brigade Response on the Airpor t
1 .14 .4
Fire Brigade Response Outside the Airport
1 .15
Survival Aspect s
1 .16
Tests and Researc h
1 .16 .1
Metallurgic Investigation of Outboard Midspar Fuse Pi n
1 .16 .2
Metallurgic Investigation of Inboard Midspar Fitting Lug
1 .16 .3
1 .16 .4
1 .16 .5
1 .17
1 .17 .1
1 .17 .2
Bird Impac t
Sabotag e
Trajectory Engine No . 3
Additional Informatio n
Other Related Incidents and Accident s
Additional Investigatio n
2 ANALYSI S
2 .1
Genera l
2 .2
Engine Pylon Separatio n
2 .3
Design and Certification Assessmen t
2 .4
Final Loss of Contro l
2 .4 .1
Controllabilit y
2 .4 .2
Performanc e
2 .4 .3
Synthesi s
2 .5 .
Performance of the Flight Cre w
2 .6
ATC Performanc e
2 .7
Actions Taken Since the Acciden t
3 CONCLUSION S
3 .1
Finding s
3 .2
Probable Cause s
4 RECOMMENDATION S
5 APPENDIXE S
1
PHOTOGRAP H
2 .1
DESCRIPTION AND MAP OF WRECKAGE AREA AFTE R
ENGINE SEPARATIO N
2 .2
DESCRIPTION AND MAP OF MAIN IMPACT ARE A
3 .1
RADARPLOT (Including key parts of RT )
3 .2
MAP OF THE RECONSTRUCTED FLIGHT PAT H
4 .1
TRANSCRIPT ATC COMMUNICATIONS AND TELEPHON E
COMMUNICATION S
4 .2
TRANSCRIPT ATC CONVERSATION WITH COASTGUAR D
6 REFERENCE S
1
NLR REPORT CR 93030C (Outboard midspar fuse pin )
2
NLR COMMENTS ON FATIGUE STRIATION INTERPRETA TION S
3
NLR REPORT CR 92454C (Inboard midspar fittings )
4
NLR REPORT CR 93248C (Wing forward beam )
5
BOEING REPORT : RESULTS OF DFDR-ANALYSIS AN D
PILOTED SIMULATION S
6
BOEING REPORT: ANALYSIS OF ENGINE SEPARATIO N
SCENARIO S
7
RLD/LI/LW REPORT : EL AL FLIGHT 1862 PERFORMANC E
CAPABILITY EVALUATIO N
8
BOEING REPORT ON METALLURGICAL INVESTIGATIO N
9
EL AL COMMENTS ON STRESS ANALYSIS AN D
FRACTOGRAPH Y
10
ISRAEL INSTITUTE OF TECHNOLOGY REPORT : ANALY SIS OF OUTBOARD FUSE PIN FAILUR E
11
COMPILATION OF APPLICABLE AD's AND SB' s
12
BOEING MANDATORY SB's CONCERNING PYLO N
CONSTRUCTION IMPROVEMENTS (pending )
13
BIRD MIGRATION REPORT ROYAL NETHERLANDS AI R
FORCE
SYNOPSIS
On October 4, 1992, at 17 :20 UTC, El Al Israel Airlines (ELY) Fligh t
1862, a Boeing 747-200 Freighter, with three crewmembers and on e
non-revenue passenger on board, took off from runway OIL at Schip hol Airport and followed the Pampus departure as cleared by ai r
traffic control services .
At 17 :27 .30 UTC, with the aircraft at flight level 65, engine no . 3 an d
its pylon separated from the aircraft and damaged part of the leadin g
edge of the right wing . The no . 3 engine then struck engine no . 4 ,
causing this engine and its pylon to depart the wing . During a n
attempt to return to Schiphol Airport control was lost and at 17 :3 6
UTC the aircraft crashed into a residential area in a suburb of Amster dam .
An investigation was initiated by the Netherlands Accident Investigation Bureau . The investigation team was assisted by specialists fro m
the Aeronautical Inspection Directorate of the Department of Civi l
Aviation . Following the procedures contained in International Civi l
Aviation Organization (ICAO) Annex 13, Accredited Representative s
and their advisors from Israel and the United States joined the investigation . Several organizations collaborated in the data extraction an d
analysis of the Digital Flight Data Recorder (DFDR) . The Nationa l
Aerospace Laboratory of the Netherlands was tasked with severa l
special projects . The Air Branch of the Netherlands State Police assis ted with the questioning of witnesses . Identification of the victim s
was carried out by the Disaster Identification Team of the State
Police .
This report is issued by the "Raad voor de Luchtvaart" (Netherland s
Aviation Safety Board) .
All times in this report are UTC unless stated otherwise .
1 FACTUAL INFORMATIO N
1 .1
History of the fligh t
The aircraft was on a flight from John F . Kennedy Internationa l

Airport, New York, to Ben Gurion International Airport, Tel Aviv, wit h
an intermediate stop at Schiphol Airport for a crew change and carg o
processing . The aircraft arrived in Amsterdam at 13 :40 and wa s
scheduled for departure at 16 :30 but received an air traffic control slo t
time of 17 :20 for departure . The maintenance transit check wa s
carried out . The aircraft was refuelled with 74,200 litres of Jet Al fuel ,
making the total amount of fuel on board of 72 metric tons . The fou r
people on board the aircraft at take off were the captain, copilot, fligh t
engineer, and one non-revenue passenger . There was a total of 114 . 7
metric tons of cargo on board of which 6 .5 metric tons were considered low grade dangerous goods .
The flightcrew involved in the accident had arrived at Schipho l
Airport on a previous El Al flight and had 20 hours crew rest prior t o
the beginning of their crew duty .
The air traffic situation at Schiphol Airport prior to the departure of E I
Al 1862 was not extraordinary, according to ATC witnesses . Tw o
runways were in use, 01 L for take off and 06 for landing . There wa s
moderate inbound traffic for runway 06, a moderate number o f
departures from 01 L and several VFR flights over the northern part o f
the city of Amsterdam . From the beginning of El Al 1862's emergenc y
declaration, air traffic services for the flight were provided by Amster dam Radar on 124 .87, Schiphol Approach on 121 .2, Schiphol Arriva l
on 118 .4 and indirectly by Schiphol Tower .
The captain requested clearance for push back at 17 :04 . The aircraft
taxied out at 17 :14 . The copilot was to be the pilot flying (PF), and th e
captain was to be the pilot not flying (PNF) . The takeoff roll o n
runway OIL started at 17 :21, with a takeoff gross weight of 338 . 3
metric tons, and the aircraft followed the Pampus departure a s
cleared by ATC . The performance limited maximum takeoff gros s
weight for the prevailing conditions of the flight was 359 .3 metri c
tons . No anomalies were evident during the initial climb unti l
17 :27 .30, as the aircraft was passing through an altitude of abou t
6,500 feet . The flight data recorder revealed that the no . 3 and 4
engines and their pylons departed the right wing at this time . Th e
copilot then transmitted the emergency call, "El Al 1862, mayday ,
mayday, we have an emergency" . The aircraft turned to the right, an d
according to witnesses on the ground, started dumping fue l
immediately . The Amsterdam Radar controller confirmed th e
emergency call and immediately cleared the area of other traffic . At
17 :28 .06 the controller, not knowing the reason for the emergenc y
call, asked the crew if they wanted to return to Schiphol Airport .
After the acknowledgement by the crew of their intention to return t o
the airport they were instructed to turn to heading 260 and wer e
informed about their position relative to Schiphol Airport . At 17 :28 .1 7
the crew reported a fire on engine no . 3 and subsequently the y
indicated loss of thrust on engines no . 3 and no . 4 .
Witnesses heard one or more banging sounds and saw a dark plum e
of smoke trailing the aircraft . Some witnesses saw objects fall . Othe r
witnesses also saw fire on the right wing which eventually disappeared . When the aircraft turned right two vapour trails were seen t o
emerge from the wingtips .
7
At 17 :28 .57, El Al 1862 was informed that runway 06 was in use an d

the wind was 040 at 21 knots . The flight crew however requeste d
runway 27 for landing . ATC then asked the crew if they could switc h
radio frequency to Schiphol Approach Control on 121 .2 megahertz .
The crew immediately switched frequency to Approach Control .
Subsequently the flightcrew was instructed to switch to Schipho l
Arrival on 118 .4 megahertz . Because the aircraft was only 7 mile s
from the airport and still flying at an altitude of 5,000 feet, a straight i n
approach was not feasible and the crew was instructed to turn righ t
to heading 360 and descend to 2,000 feet . The crew was again informed about the wind (by then 050 at 22 knots) .
About one minute later at 17 :31 .17 the controller asked what distanc e
they required to touchdown . Shortly thereafter, the controller aske d
for the number of track miles the flight crew required for an approach . The crew stated that they needed "12 miles final for landing" .
Together with this reply to ATC, the call "Flaps 1" could be heard a s
background conversation in the cockpit . ATC instructed El Al 1862 to
turn right to heading 100 . During the turn the controller asked for th e
status of the aircraft and was informed : "No . 3 and 4 are out and we
have problems with the flaps" . The airplane had turned throug h
heading 100 and was maintaining heading 120 . No corrective actio n
was taken by the controller . The aircraft maintained an airspeed o f
260 knots and was in a gradual descent .
El Al 1862 was cleared for the approach and directed to turn right t o
heading 270 to intercept the final approach course . The airplane wa s
then at an altitude of about 4,000 feet, with a groundspeed of approximately 260 knots and on heading 120 .
The position was 3 nautical miles north of the centreline of runway 2 7
at a distance of about 11 miles projected on the extended centrelin e
of runway 27 . According to the radar plot, it took about thirty second s
before the aircraft actually changed heading .
When it became apparent that the airplane was going to overshoo t
the localizer, the controller informed the crew accordingly and directed the aircraft to turn further to heading 290 in an attempt to intercept the final approach again but now from the south . Twenty
seconds later a new heading instruction to 310 was given, along wit h
descent clearance to 1,500 feet .
The flightcrew acknowledged this instruction at 17 :35 .03 and added ,
"and we have a controlling problem" . Approximately 25 second s
later the copilot called, "Going down 1862, going down
" . In th e
first part of this transmission commands from the captain to raise al l
the flaps and to lower the landing gear could be heard . During th e
middle part of this transmission a sound was heard, and in the fina l
part of the transmission another sound was audible . These sound s
were later analyzed and determined to be the stick shaker and th e
ground proximity warning system respectively .
The airplane crashed at 17 :35 .42 into an eleven-floor apartmen t
building in the Bijlmermeer, a suburb of Amsterdam, approximatel y
13 km east of Schiphol Airport . The impact was centred at the apex o f
two connected and angled blocks of apartments and fragments of th e
aircraft and the buildings were scattered over an area approximatel y
400 meters wide and 600 meters long . Firefighting and rescue operations started shortly after the crash .
The aircraft was destroyed by the impact and the resulting fire . Th e
accident occurred during dusk .
1 .2
Injuries to person s
Injuries
Crew
Fatal
Seriou s
Minor/Non e
1 .3
Passengers
Others
43
Damage to Aircraf t
At the time the pylons and the engines separated from the wing, th e
leading edge of the right wing, between engine no . 3 and 4, wa s
extensively damaged, along with several airplane systems in tha t
area . At final impact, the aircraft was destroyed by impact forces an d
the ensuing explosion and fire .
1 .4
Other damag e
The airplane impacted into the apex of two connected and angle d
apartment buildings which were partly destroyed by the impact an d
subsequent fire . The damage to the structure of the buildings precluded their reconstruction and the two buildings were torn down .
The soil in the impact area was heavily contaminated with airplan e
fuel, oil and combustion products of the airplane and freight .
1 .5
Personnel Information
The Captai n
a.
date of birth : 21-01-193 3
b.
nationality : Israel i
c.
profession : Airline Transport Pilot employed by El Al sinc e

02-08-1964 .
d.
last medical check : 07-07-1992 .

Result : qualified medical certificate group I, must wea r
correcting glasses while exercising the privileges of thi s
licence .
Valid until : 31-01-199 3
e.
licence : Israeli ATPL no . 340, first issue 20-09-1960 .

Date of last validation : 11-04-1992 .
The ratings on the ATPL were : Group A + C : B707, B747 ,
DC3, Instrument airplane s
f.
total flying experience : 25,000 hours flying experience . B747 :

9,500 hours of which 233 hours in the last 3 precedin g
months .
g.
additional information :
- holder was qualified as captain on the B747 on 02-07-1981 ;
- holder was qualified as instructor on 01-09-1992 ;
- last flight was on 03-10-1992 on the route from Tel Aviv t o
London, to Amsterdam . After resting 20 hours, he repor ted for duty on 04-10-1992 .
The First Office r

a.
b.
c.
profession : Airline Transport pilot with El Al sinc e

17-11-199 1
d.

Result : qualified medical certificate group I, unrestricted .
Valid until : 20-06-1993 .
e.
licence : Israeli ATPL no . 2844, first issue 04-11-1987 .

The ratings on the ATPL were : Group A + B + C ; B707 ,
1A-1124, ARAVA 101, C12D, Instrument airplanes .
Group Il : B747 .
f.
total flying experience : 4,288 total hours ; flying experienc e

on the B747 : 612 hours of which 151 hours in the last 3
months .
g.
- holder became a qualified First Officer on the B74 7
on 31-03-1992 . He was released from all limitations as a
"new pilot" since 23-04-1992 ;
- last flight was on 03-10-1992 on the route Tel Aviv London -Amsterdam . After resting 20 hours he reporte d
for duty on 04-10-1992 .
The Flight Enginee r

a.
b.
c.
profession : Flight Engineer with El Al since 19-06-195 5
d.

Result : qualified medical certificate group I, must wea r
correcting glasses while exercising the privileges of thi s
licence .
Valid until : 28-08-1993 .
e.
licence : Israeli Flight Engineers license no . 82 .

Year of first issue : 1956 .
The ratings on the F/E licence were : Turbojet powere d
airplanes ; B707, B747 .
f.
total flying experience : 26,000 hours ;

flying experience on the B747 : 15,000 hours of which 22 2
hours in the last 3 preceding months .
g.
- holder joined El Al as a mechanic in 02-01-1950 ;
- holder became a qualified Flight Engineer for B74 7
on 25-11-1971 ;
- holder was qualified as Flight Engineer instructor fro m
01-02-74 till 22-05-199 1
e
- holder functioned as supervisor Flight Operations, in th
period 1974 - 1976 ;
10
- holder left El Al on 22-05-1991 for a period of 3 month s

and returned to active flight duties at the end of thi s
period ;
- last flight was on 03-10-1992 on the route Tel Aviv
London - Amsterdam . After resting 20 hours he reporte d
for duty on 04-10-1992 .
Remarks : Captain, First Officer and Flight Engineer passe d
their line and simulator checks in accordance with th e
approved training and qualifications program .
1 .6
Aircraft Information
1 .6.1
Genera l
a.
nationality and registration : Israel, 4X-AX G
b.
aircraft type : Boeing 747 Freighter ; Type : 258 F

serial no . : 2173 7
year of construction : 197 9
manufacturer : Boeing Commercial Airplane Compan y
c.
engines : 4 Pratt & Whitney JT9D-7 J

fuel : Jet A 1
d.
The aircraft was registered in the Israeli aircraft registe r

dated 19-03-1979, under the name of El Al Israel Airline s
Ltd ., address : Ben Gurion Airport, P .O . Box 41, Israel 70100 .
e.
The Certificate of Airworthiness form 105 was issued at 15 03-1992 and valid until 15-03-1993 .
f.
At the time the aircraft departed Amsterdam Airport, th e

take off gross weight was 338 .3 metric tons and the centre o f
gravity (CG) for take off was 23 .1 percent mean aerodynami c
chord (MAC), which was within the limits of the aircraft' s
flight envelope .
g.
Additional information :
This Boeing 747-258 cargo transport category airplane wa s
manufactured in accordance with Federal Aviation Administration (FAA) type certificate no . A20W, as approved on 30 12-1969 . The aircraft was certificated in accordance with th e
provisions of 14 CFR Part 25, effective on 01-02-1965 .
The aircraft was powered by four Pratt & Whitney JT9D-7 J
high bypass ratio turbofan engines . The JT9D engine wa s
certified by the FAA on 31-08-1976 with Type Certificate Data
Sheet E20EA .
The aircraft accumulated 45,746 flight hours and 10,10 7
flight cycles . Maintenance records indicate that the aircraf
t
and the Pratt & Whitney JT9D-7J engines were inspecte d
and maintained in accordance with the EI Al maintenanc e
program, the Boeing Maintenance Plannin g
Document, the Maintenance Review Board Report, and EI A l
Engineering and Quality Control Division requirements an d
recommendations .
11
All the required inspection and maintenance actions ha d

been completed and all applicable airworthiness directive s
(AD's) had been accomplished, or were in the process o f
being accomplished within the specified time limits .
Examination of the service records, crew write-ups, actio n
items, trend monitoring data, and flight recorder data o f
previous flights did not reveal any significant deviations .
1 .6 .2
Pylons, Fuse Pins and Nacelle Attach Fitting s
The pylon, fuse pins and attachment fittings that comprise th e

engine/pylon/wing attachment system were inspected according t o
the applicable Service Bulletins (SB's), Service Letters (SL's) and FA A
Airworthiness Directives (AD's) . The Civil Aviation Authority of Israe l
does ratify all FAA issued AD's .
Since the last inspection of the midspar fuse pins of pylo n
no . 3 on June 17, 1992, the aircraft accumulated 257 flight cycles unti l
the accident .
1 .6 .3
Aircraft Desig n
1 .6 .3 .1
Pylon to Wing Attachment Desig n
The design of the engine nacelle and pylon incorporate s

provisions that preclude a wing fuel cell rupture in case of engin e
separation, by means of structural fuses . A clean breakaway of th e
nacelle and/or pylon from the wing is ensured when the shearloadin g
of the fuse pins exceeds the design load conditions .
The structural fuse concept utilizes hollow shear pins at the four win g
attachment fittings between pylon and wing . The wing support structure and fittings have been designed sufficiently stronger than th e
fuse pins thus safeguarding the wing from structural damage in cas e
of an overload condition .
The nacelle and engine are attached to the pylon bulkheads throug h
forward and aft engine mount fittings .
The pylon is essentially a two cell torque box containing thre e
bulkheads : a forward engine mount bulkhead, an aft engine moun t
bulkhead and a rear closure bulkhead . Pylon to wing attachments ar e
made at the aft end of the upper link, the aft end of the diagonal brac e
and at the two pylon midspar fittings .
The fuse pin at the forward end of the upper link, the aft end of th e
diagonal brace and at both midspar fittings are the primary fuse pins .
The fuse pins at the forward end of the upper link and the aft end o f
the diagonal brace are designed to fail at a slightly lower load tha n
the fuse pins at the other ends in order to assure a controlled separation of the pylon from the wing .
Nacelle load components in the vertical and side directions are absorbed by the forward pylon bulkhead while vertical, side, torque an d
drag components are reacted at the aft mount bulkhead . These pylo n
loads go to the four wing attachment fittings through the pylon fron t
spar and lower spar, the midspar and the pylon skin . Primary dra g
loads go through a thrust link into the diagonal brace . An additiona l
side brace from the pylon midspar to the wingbox takes pylon sid e
shear into the wing . A schematic of the pylon to wing attachment s
fittings is given in figure 1 .
12
1 .6 .3 .2
Hydraulic System s
Four separate and independent main hydraulic supply systems ar e

provided to meet the power requirements of the flight control an d
landing gear systems . Each main supply system is associated with a n
engine with most of its components located in the pylon area abov e
and aft of the engine . See figure 2 .
The four main hydraulic supply systems are functionally identical .
The systems differ only in reservoir capacity and the location of som e
components . Hydraulic power for each system is provided by tw o
pumps installed in parallel . An engine driven pump is in operation a t
all times when the airplane engine is running . This pump is supplemented by an air driven pump powered by the pneumatic system an d
controlled from the flight engineer's station . The air driven pump ca n
be turned off, run continuously or be operated in the automati c
mode, where it will remain off until the demand exceeds the capacit y
of the engine driven pump .
Hydraulic system indications and warnings include standard pressur e
and fluid quantity gages and indicating lights .
1 .6 .3 .3
Pneumatic Syste m
The pneumatic system consists of a manifold of ducts and valves tha t

supplies hot air from the engine for the airconditioning and th e
pressurization system, engine starting, and thermal anti-icing . Blee d
air is also used to actuate the leading edge flaps, air driven hydrauli c
pumps, lower cargo compartment heating, potable water system s
pressurization and thrust reversers .
The primary supply of pneumatic air is from the mid compresso r
stage of each engine, through a check valve . When mid stage blee d
air pressure is not high enough to supply system demands, hig h
stage bleed air is used . Switching from low to high stage bleed o n
each engine is controlled automatically by the high stage bleed ai r
valve .
The pneumatic manifold is separated into left, right, and centr e
sections by two wing isolation valves . See figure 3 .
13
HYD SY S
NO . 1
HYD SYS' '

NO . 2
HYD SY S
NO . 3
~, _.rr7?aYltMnl~F'.
e. .ner,-fa .. .. ...r
NO . 4
,
WING GEA
NOSE GEA R
BODY GEA R
STEERIN G
Inboard
Trailin g
Edge FLAPS
SINGL E
SOURC E
SYSTEMS
-r
DUA L
SOURC E
SYSTEMS
L . Outboard
ELEVATOR

SPOILER S
2, 3, 10, 1 1
SPOILER S
1,4,9, 12
RESERV E
BRAKES
SPOILER S
5, 6, 7, 8
Outboard
Trailin g
Edge FLAPS
A/P B
CONTRO L
INPUTS
A/ P A
CONTRO L
INPUTS
mmmmmmmmmmmm m
mmmmmmmmmmmm m
mmmmmmmmmmmm m
CENTRA L
CONTRO L
ACTUATO R
NO . 1
ELEVATO R
FEE L
CENTRA L
CONTRO L
ACTUATO R
NO . 2
STABILIZE R
TRIM
L . Outboard
AILERON
R . Outboard
AILERO N
R . Inboar d
ELEVATOR
L . Inboar d
ELEVATOR
L . Inboard AILERO N
Upper RUDDE R
R . Inboard AILERO N
Lower RUDDE R
NORMAL BRAKE S
R . Outboard
ELEVATO R
mmmmmmmmmmmmm m
AC
PAC K
1
AC
PAC K
2
CONDITION :
CRUIS E

BLEED AI R
=FAN AI R
AC
PAC K
3
L .E .
FLAP S
WIN G
ANTI . IC E
AI R
DRIVE N
HY D
PUM P
AI R
DRIVE N
HY D
PUMP
HYD . RES .
HYD . RES .
PRESS
PRESS
AP.U
BLEED AIR
OrIN
- -
__).H,
GR D
CARTS
(3 )
nose
J
r
!
i
uuu
~ 'ir4'\ex
~
- fC-._..~r.C.+yMplr...qq-1
.98s
Figure 3 .
PNEUMATIC SYSTEM
16
1 .6 .3 .4
Electrical Syste m
AC Powe r
Primary AC power is supplied by four engine driven generators . Fou r
AC busses are directly fed from their associated generators . Connection of these busses to a sync bus allows parallel operation . A spli t
system breaker in the sync bus permits division of the bus syste m
into two independent halves . The engine driven generators can b e
paralleled in any combination .
An essential AC bus can be powered independent from the main A C
busses . A standby AC bus uses a battery powered static inverte r
when no other source of AC power is available .
DC powe r
Primary power for the DC busses is obtained from the main A C
busses through transformer/rectifier units .
Secondary DC power is available from the main battery for th e
battery busses .
1 .6 .3 .5
Flight Controls
Primary airplane control is provided by ailerons, elevators, an d

rudders . The control surfaces are positioned by hydraulic powe r
packages served by four independent hydraulic systems . Control o f
the surfaces is accomplished by conventional duplicated ailero n
control wheels, control columns, and rudder pedals . The distributio n
of hydraulic supply from the various hydraulic systems to the variou s
control surfaces is presented in figure 2 .
The rudder control system contains a rudder ratio changer, whic h
modifies the relationship between rudder pedal and rudder deflectio n
in such a way that at a constant rudder pedal position the rudde r
deflection decreases with increasing speed, for reasons of structura l
protection .
Additional controls consist of trailing edge flaps, leading edge flaps ,
spoilers and an adjustable horizontal stabilizer . Trailing edge flap s
are hydraulically powered and controlled by a flap control lever in th e
pilot's control stand . Leading edge flaps are primarily powered b y
pneumatic motors which are controlled by an electrical output fro m
the trailing edge flap system . Back-up power to the leading edge an d
trailing edge flaps is provided by electric motors which are controlle d
by switches on the pilot's overhead panel .
The spoilers are hydraulically powered from different hydrauli c
systems . When used for lateral control, the spoilers are positioned b y
an output from the aileron control system . When used as spee d
brakes, the spoilers are controlled by a speed brake control lever . Th e
horizontal stabilizer is positioned by hydraulic motors controlle d
primarily by trim switches on the control wheels . Levers on the pilots '
control stand provide an alternate mechanical method of controllin g
the hydraulic actuators of the horizontal stabilizer that overrides al l
other command signals .
At higher speeds the outboard ailerons are normally locked out an d
kept in a neutral position by a lockout mechanism . To unlock th e
outboard ailerons the outboard trailing edge flaps must move mor e
then 0 .5 degree and the DC essential bus must be powered . Inabilit y
to extend the outboard trailing edge flaps via the normal (hydraulic )
or alternate (electrical) means results in unavailability of the outboar d
ailerons .
17
1 .6 .3 .6
Fuel Syste m
The airplane fuel system provides a means of storing fuel in th e

airplane, provisions for distribution to the engines, provisions fo r
pressure fuelling and defuelling, a fuel jettison system and an electronically controlled fuel quantity indication system .
All fuel is stored in the wing and wing centre section . The tank section s
are integral tanks, utilizing the sealed structure to retain the fuel .
Fuel is fed into the pylon compartment via the engine fuel shut of f
valve . This valve is mounted on the front spar inside the wing tan k
and can be closed to isolate the engine from its fuel . When shuttin g
the engine down by pulling the fire handle, this valve is commande d
closed . This valve can also be closed by placing the start lever to th e
cut-off position .
Fuel jettison is accomplished through separate pumps except for th e
centre wing tank where override/jettison pumps serve a dua l
purpose . Tank interconnection for fuel feed and jettison is limited t o
gravity feed transfer from the reserve tanks to the main tanks, and i s
controlled by electric motor operated valves . All pump and valv e
controls, along with fuel quantity indicators and indicating lights, ar e
located on the flight engineer's panel .
1 .6 .3 .7
Engine Fire Detection and Extinguishing System s
The engine fire detection system on each engine consists of tw o

continuous sensor loops and a fire detection electronics module .
Cockpit fire warning is provided by illumination of engine fir e
handles, master warning lights and a cancellable fire warning bell . O n
the flight engineer's panel a fault indicator light is provided t o
indicate when any of the 8 engine loops has failed . The nacell e
temperature indicator will indicate which loop is faulted .
Each sensor loop is located at the critical locations throughout th e
engine, such that a fire will trigger the sensor . Normally the detectio n
logic requires fire signals from both sensor loops, before a fire
warning is generated in the cockpit . This design feature is intended t o
reduce the probability of false warnings . The corresponding syste m
configuration is called : "BOTH" .
The engine fire detection loops consisted of an inconel tube containing thermistor (thermal resistor) material in which one electri c
conductor is embedded . If the temperature rises, the resistance
between the conductors drops and within certain rate of change o f
resistance criteria the signal is treated by the fire detection electronic s
module as a fire signal .
In case of a short circuit between the two conductors the fire detectio n
electronics module determines a fault signal for the respective loop .
The logic used to indicate a fire warning in the cockpit with the fire
detection system in the configuration "BOTH" is as follows :
Loop A sense
Loop B sense
Indicatio n
fire
fire
fire
fault
fault
fire
fault
none
fault
none
fire
fire
faul t
fire
fault
Logic of fire warning indication
18

From the table above it can be concluded, that with the fire detectio n
system in the normal "BOTH" configuration, if both loops detect a
fault signal, a fire warning will be generated in the cockpit . Accordin g
aircraft operating procedures the engine fire procedure should tha n
be executed .
Engine fire extinguishing is provided by two bottles per engine wit h
an extinguishing agent, which are located in the pylons . In the cockpi t
just below the engine fire handles an electrically signalled "BOTTL E
DISCHARGED " light is provided which illuminates, when the indicated bottle has been discharged .
1 .6 .4
Service Bulletins and Airworthiness Directive s
Since the certification of the Boeing Model 747 numerous Servic e

Bulletins and Airworthiness Directives were issued by Boeing and th e
FAA . For an overview see reference 11 .
The most significant Service Bulletins and Airworthiness Directive s
concerning the pylon structure are explained in more detail in th e
following subchapters .
1 .6 .4 .1
Service Bulletins Applicable to Midspar Fuse Pin s
The first Service Bulletin for midspar fuse pins, SB 747-54-2063, wa s

issued on August 10, 1979, after Boeing was informed in the lat e
1970's of cracks in the original, old style "bottle bore" configuratio n
midspar fuse pins . This Service Bulletin recommended repetitiv e
inspections of old style fuse pins for cracks every 2,500 flight hours . I t
also recommended an inspection for corrosion and application o f
corrosion preventive compound (CPC) . The FAA made the recommended inspections mandatory in AD 79-17-04 .
Revision 1 of this Service Bulletin, issued August 13, 1981 provide d
the terminating action for the repetitive inspections of old style pin s
by replacement with new pins having a "bulkhead" configuration .
The FAA subsequently amended AD 79-17-04 on March 16, 1982, t o
announce that installation of the new style fuse pins was a terminating action for the repetitive inspection requirement .
In 1986, Boeing issued a revised ultrasonic procedure for improve d
detection of cracks in old style fuse pins (SB 747-54-2063R4) . The FAA
made the improved procedure mandatory with AD 86-22-01, that als o
superseded AD 79-17-04 .
In April 1988, Boeing received a report of a crack in a new style fus e
pin . Analysis of the pin indicated that the crack initiated from corrosion pits on the inner diameter of the fuse pin . The corrosion pit s
were attributed to the absence of primer and CPC on the inner surfac e
of the fuse pin .
In response, on March 29, 1990, Boeing issued Revision 7 to SB 747 54-2063, adding instructions for an one-time inspection of new styl e
fuse pins for the presence of CPC .
The FAA issued a Notice of Proposed Rule Making (NPRM) o n
November 6, 1990, proposing to require an one-time inspection o f
new style fuse pins for the presence of primer and CPC per SB 747 54-2063, Revision 7, prior to the accumulation of 12,000 flight hour s
after the effective date . This revision was made mandatory with th e
issuance of AD 91-09-01 on May 28, 1991 .
In January 1992, Boeing began a review of the in-service history o f
the new style fuse pins . The review was initiated due to reports of
19
corrosion in new style fuse pins that reportedly had been inspecte d
per AD 91-09-01 . At that time, Boeing had received only five report s
of cracks in new style fuse pins . In these cases the crack initiated i n
corrosion pits and the pins did not have the required primer and/o r
CPC . However, during the spring and summer of 1992, as th e
deadline for inspecting new style fuse pins pursuant to AD 91-09-0 1
took effect, Boeing received additional reports of cracks in new styl e
fuse pins .
From the time of the original installation of new style fuse pins i n
1980, through September 1992, 14 instances of cracks in new styl e
midspar fuse pins and 9 reports of cracks in new style diagonal brac e
fuse pins were reported to Boeing . Boeing began an engineerin g
investigation of other fuse pin designs and undertook to develo p
procedures for ultrasonic inspection of new style fuse pins for cracks .
An All Operators meeting was held in Seattle, on September 21, 1992 ,
to discuss the in-service history of new style fuse pins and the forth coming Boeing recommendation for repetitive ultrasonic inspection s
of new style fuse pins . Boeing informed operators that it was developing a new style fuse pin to replace all B747 midspar fuse pins an d
described the pin development schedule .
1 .6 .4 .2
Service Bulletins Applicable to Diagonal Brace Fuse Pin s
Service bulletin 747-54-2066 was issued November 7, 1979, afte r

Boeing had received reports of fractured diagonal brace to inboar d
engine strut fuse pins .
Analysis indicated that the fractures were caused by cyclic loading ,
and initiated in an circumferential machining groove in the pin bor e
inboard recess .
Boeing recommended a visual or ultrasonic inspection upon accumulation of 5,000 or more flights and recommended repeat inspection s
visually every 350 flights or an ultrasonic inspection every 1,20 0
flights, until the pins were replaced with a new design pin for terminating action . This service bulletin was effective for B747 airplane s
with Pratt and Whitney JT9D-70 engines only . The FAA issued AD 79 22-03, making provisions of the SB mandatory .
Service Bulletin 747-54-2101 was issued April 11, 1983, after Boein g
received reports of fractured diagonal brace to wing fuse pins . Boein g
recommended a visual or ultrasonic inspection upon accumulation o f
5,000 flights on the pins, and advised repeat inspections every 35 0
flights visually or 1,200 flights ultrasonically . When cracks were
found, the existing pin had to be replaced with the new improve d
design pin .
This Service Bulletin was made applicable to all B747 airplanes wit h
JT9D, CF-6 and RB211 engines . FAA issued AD 83-24-05, makin g
provisions of this SB mandatory .
With Service Bulletin 747-54-2102, Boeing recommended that opera tors replace the inboard and outboard upper link and outboar d
diagonal brace fuse pins to reduce the possibility of fuse pin fracture ,
although no fuse pin fracturing of those fuse pins had been reported .
This Service Bulletin was not made mandatory by FAA .
1 .6 .4 .3
Service Bulletins Applicable to Attach Fittings
Service Bulletin 747-54-2062 was issued August 17, 1979, after opera tors reported cracks in the inboard engine strut to diagonal brac e
attach fittings . Boeing recommended an inspection upon accumulation of 5,000 flights, and a reinspection interval of 1,000 flights if no
20

cracks were found . FAA mandated the Service Bulletin with AD 79-17 07 .
Service Bulletin 747-54-2100, issued June 20, 1983, prescribes a n
ultrasonic inspection of the inboard and outboard midspar fitting o r
spring beam aft lugs of each pylon for cracks initiating in the lu g
bores . Some operators had reported lug corrosion and in one cas e
both lugs of the inboard pylon were found broken . Analysis of th e
broken part indicated that the breaks were the result of fatigu e
cracking initiating at corrosion pits in the bore surface of the outer lu g
fitting . AD 85-22-07, dated November 24, 1985 was issued to mak e
provisions of the SB mandatory .
1 .6 .4 .4
Service Bulletins Applicable to the Nacelle Strut Rear Engin e

Mount Bulkhea d
Service Bulletins 747-54-2033/2042/2059 and 2065 cover the subject s

of nacelle strut engine aft mount bulkhead cracking, inspection an d
modification .
Although the majority of cracks in the aft mount bulkhead was foun d
on B747's with Pratt and Whitney JT9D-7 engines, the SB also applie d
to the General Electric CF6 and Pratt and Whitney JT9D-70 powere d
airplanes . These SB's were not adopted as FAA Airworthiness Directives .
1 .7
Meteorological Informatio n
Weather information was obtained from the meteorological servic e

of the Royal Dutch Meteorological Institute at Schiphol Airport .
1 .7 .1
General Condition s
A high pressure area centred over the southern part of Scandinavi a

and a low pressure area centred over the Gulf of Genua created a
strong north easterly flow of dry air over the Netherlands at the tim e
of the accident .
1 .7 .2
Conditions at the time of the Cras h
altitude ft
wind degrees/knots
temperature c-C
groundlevel
040/23 gust 33
50/30-35
50/35-40
70/40
70/30-35
13
12
10
10
8
1,0000
2,0000
3,0000
5,0000
Wind and temperature condition s

visibility :
- from the ground to 2,000 feet, 15 kilometres .
weather :
- clear and dry .
clouds :
- 1/8 alto cumulus at 13,000 feet .
freezing level :
- 8,000 feet .
21
turbulence :
- light to moderate .
light condition :
- dus k
1 .7 .3
Aerodrome Terminal Information Service CATIS)
When requesting the airway clearance, the crew informed ATC tha t
they received ATIS information "Tango" . Information Tango reads :
Main departure runway 01 L, main landing runway 06 ,
040 degrees 23 knots, maximum 30 knots, minimum 1 3
knots, temperature 14, dewpoint 8, QNH 1012 hectopascals .
1 .8
Aids to Navigatio n
All ground navigational aids for the Pampus departure and the instrument landing system for runway 27 were fully serviceable .
1 .9
Communications and Recording s
1 .9 .1
ATC Communication Recording s
All ATC communications were recorded on a magnetic tape recording system, with a time coding .
A transcript of the relevant ATC, airport, and fire brigade communication recordings is attached as Appendix 4 . 1
1 .9 .2
Other Communication Recording s
The recording system also records a number of telephone lines .

A transcript containing information received from the Rescue Coordination Centre in IJmuiden (RCC) is attached a s
Appendix 4 .2 .
1 .9 .3
Radar Data Recording s
Information from the Schiphol primary and secondary radar was als o
continuously recorded on tape . A videorecording of the replay of th e
radar tape was made, and later, the radio conversations with th e
aircraft were dubbed onto the videotape .
A plot of the radar tape, together with key transmissions from th e
radio telephony, is attached as Appendix 3 .1 . This plot has bee n
transferred onto a map in Appendix 3 .2 .
1 .10
Airport Informatio n
Schiphol Airport is located to the southwest of Amsterdam . Runwa y

01L was in use as the preferential take off runway and runway 06 a s
the preferential landing runway .
After the El Al 1862 emergency call was made and after the fligh t
crew requested to land on Runway 27, this runway was made available and the runway and approach lighting were activated .
All required services were operational .
1 .11
Flight Recorders
1 .11 .1
Digital Flight Data Recorde r
The El Al aircraft was equipped with a Sundstrand Digital Flight Data
22
Recorder (DFDR) . The following information applies to the DFDR :

Model
: 57 3
Manufacture Part No . : 981-6009-01 1
Manufacture Ser . No . : 279 3
The DFDR was removed from the accident site and transported vi a
the Netherlands Accident Investigation Bureau in Hoofddorp to th e
Aircraft Accident Investigation Board (AAIB) in Farnborough ,
England, and from there to the Engineering Services Division of th e
NTSB in Washington D .C ., USA.
The DFDR was found in a heavily damaged condition . The outer cas e
suffered massive impact damage during the crash and was furthe r
damaged by post-crash fire .
The shock and heat resistant crash protection unit, which containe d
the DFDR tape and the tapedrive mechanism, was slightly damage d
by heat and water . Some small parts of the wiring and electroni c
circuit boards were burned .
The tape itself was found broken at four places, where it was no t
wound on the reels . The tape exhibited cracks, discoloration, an d
contamination, particular at the section that contained the information of the last two and a half minutes of the flight . A small amount o f
water was also found in the crash protection unit of the recorder .
Notwithstanding this damage, a readout was accomplished on al l
recorded parameters . Validations were accomplished on som e
parameters . The data were converted into graphical plots and tim e
correlated with the ATC time reference .
1 .11 .2
Cockpit Voice Recorder
The El Al aircraft was equipped with a Fairchild Cockpit Voice Recor der (CVR) . The following information applies to this recorder :
: A-10 0
Model
Manufacture Part No . : 93A100-3 0
Manufacture Ser . No . : 418 6
Despite intensive search activities to recover the CVR from the wreck age area, the recorder was not found . El Al personnel stated that a
CVR had been installed in the aircraft .
1 .12
Wreckage and Impact Informatio n
1 .12 .1
Impact Area of the Engines and Wing Components
Engines 3 and 4, with their related pylons, were recovered from th e

water at a position approximately 0 .5 kilometre from the entrance t o
Naarden Harbour, approximately 200 meters apart .
Numerous engine cowling and reverser parts, some parts of the righ t
wing leading edge structure, leading edge flap no . 18, a pneumati c
duct and the no . 3 and 4 diagonal braces, were found on land in clos e
proximity to the engines .
1 .12 .2
Main Impact Area
El Al 1862 crashed into an eleven-story residential building located i n

a suburb of Amsterdam, the Bijlmermeer, approximately 13 kilometres east of the airport . The impact was centred at the apex of a bloc k
of apartments and debris were scattered over an area of about 400
23
meters wide and 600 meters long . The relative small impact are a
among high obstacles such as buildings and trees, indicated a ver y
steep final flight path angle .
The scattering of fragments, in particular those of the left wing, th e
tail section and fragments of the cockpit, in combination with th e
damage of the building, indicated that the aircraft had attained a ban k
angle of slightly over 90 to the right and a nose down attitude o f
approximately 70 upon impact . The heading on impact wa s
generally to the East .
Aircraft configuration at impact was TE flaps up, LE flaps partiall y
extended, stabilizer trim approx 4 .2 units aircraft nose up, wing gear s
up, body gears and nose gear in transit .
1 .12 .3
Damage to Aircraf
t
1 .12 .3 .1
Damage to Right Wing Structur e
On land, in the area to the West and Southwest of the location wher e
engines no . 3 and 4 were recovered, several parts of the leading edg e
flaps and RH wing leading edge structure were recovered . The largest
parts comprised a slightly damaged and partly opened LE flap an d
drive (no . 18), the top skin panel above pylon no . 3 and the adjacen t
inboard top skin panel located above the most outboard Krgerflap .
The top skin panel above pylon no . 3 showed extensive chafing fro m
the pylon structure . Smaller parts of LE flaps and wing LE structur e
were found in this same area .
In the same area a slightly damaged about 2 meters long pneumati c
duct of the bleed air system was found . This part is normally locate d
in the wing leading edge, between engines no . 3 and 4 .
Engine and pylon no . 3 separated from the wing and collided wit h
engine no . 4, in an outward and rearward direction . In view of th e
amount of LE flaps and LE structure found, the right wing leadin g
edge must have been damaged up to the front spar of the right han d
wing over an area approximately 1 meter left of pylon no . 3 to appro x
1 meter right of no . 4 . It is assumed that due to the speed of th e
aircraft, the aerodynamic distortion and turbulence, some parts wer e
blown off the leading edge of the right hand wing up to the front spar .
Figure 4 illustrates the estimated damage to the right hand wing .
Note:The amount of damage on the left wing leading edge after separation of pylon no . 2 ,
from a B747 accident at Anchorage on March 31, 1993, is indicative for the amount o f
damage probably inflicted on the El Al 1862 right wing leading edge .
24
Figure 4 . ESTIMATED DAMAGE TO RH WING LEADING EDGE

25
1 .12 .3 .2 Damage to Engines

Engines no . 1 and 2
Engines no . 1 and 2 were found in the main impact area near th e
apartment building . Examination of the engine fragments and analysis of the damage indicated that the engines were operating at hig h
power up to the impact with the ground .
No evidence was found of preexisting damage to the engines whic h
might have been caused by an external or internal source .
Engines no . 3 and 4
Engines no . 3 and 4 were dredged from the lake located below th e
aircraft's flight path, together with the engine pylons and many part s
of their nose cowls and thrust reversers .
The significant damage to the engines was external and occurre d
when the engines hit the water . Internal rub marks and other witnes s
marks indicated that when the engines hit the water they were eithe r
at a low rotating speed or had stopped . Internal examination o f
engine 3 and 4 showed no abnormal signs of preexisting damage .
Significant fan blade tip rubbing was found at two places in the fa n
cases of engine 3 and 4 . This kind of damage is typical of fan blade ti p
rubbing when the engines are at a high speed of rotation . In this cas e
the location of the rub within the fan cases indicated a gyroscopi c
effect of the engine rotating parts such as the fan, the compresso r
and turbine disks, at engine separation .
Engine cowlings and pylons of engine no . 3 and 4
The engine no . 3 inlet was recovered from the lake below th e
aircraft's flight path practically intact and together with the engine ,
whereas engine no . 4 inlet was found in smaller parts . The pylons o f
engine no . 3 and 4 were still attached to the engines, however pylo n
no . 4 separated from its engine during recovery from the water .
Matching of the engine cowling and inlet parts of engines no . 3 and 4
revealed that engine no . 3 and 4 had collided . The right hand side o f
engine no . 3 inlet cowling showed a circumferential dented damag e
pattern from a rotating part which left paint smear at the three o'cloc k
position, caused by the engine no . 4 spinner .
Fairing seal of pylon no . 3
When the wing forward beam and fairing seal of pylon no . 3 wer e
recovered excessive chafing was noted at the wing forward beam .
The question arose whether or not this amount of chafing could hav e
been caused by the disconnection of either inboard or outboar d
midspar fitting . When studies carried out in relation to the "separation scenarios" showed that a fracture of either inboard or outboar d
midspar fitting/pin prior to the accident flight was highly improbabl e
this issue was not further investigated .
26
1 .12 .3 .3 Damage to Hydraulic System s

When engines no . 3 and 4 separated from the aircraft, the no . 3 an d
no . 4 hydraulic systems were severely damaged . The engine no . 3
and 4 hydraulic engine driven pumps, as well as the air driven pump s
and some of the system hydraulic lines, were found in close proximity to the engines in the lake below the flight path . Due to the sever e
damage, hydraulic systems no . 3 and 4 ceased operation, and consequently system 3 and 4 hydraulic pressure was not available to th e
relevant flight controls and other user systems .
Figure 5 gives an overview of the remaining and lost hydrauli c
systems after engine separation .
Engines no . 1 and 2 and their hydraulic pumps were not damaged i n
flight . Due to the damage to the right hand wing pneumatic ducting ,
the pneumatic pressure needed for the air driven pumps in the lef t
wing bleed air duct was lower than the normal system pressure .
1 .12 .3 .4 Damage to Pneumatic Syste m
When the engines no . 3 and 4 separated from the aircraft, th e
pneumatic system was severely damaged . An almost undamage d
component of the right wing pneumatic bleed air duct between th e
engine no . 3 and 4 was found near the engines on land below th e
flight path . The damaged bleed air pipe ducting allowed venting o f
bleed air supplied by the engines no . 1 and 2 .
Based on DFDR data for engine EPR and EGT it can be calculated that
after engines no . 3 and 4 separated, engines 1 and 2 continued to
provide enough bleed air to keep the pneumatic pressure at th e
airconditioning pack no . 3 valve position above the minimum required to keep this valve open . This valve automatically closes whe n
pressure in the duct drops below 8 psi . The DFDR data indicates tha t
the pack no . 3 valve did not close after engine separation . This als o
indicates that the pressure in the duct remained above 8 psi . Thi s
means that the wing isolation valves were in the open position .
1 .12 .3 .5 Damage to Electrical Syste m
After engine no . 3 and engine no . 4 separated from the aircraft th e
electrical power supply from generator no . 3 and no . 4 was lost .
DFDR data show that in general however electrical power remaine d
available to all electric and electronic systems . However som e
erroneous instrument indications may have been possible .
1 .12 .3 .6 Damage to Fuel Syste m
When the engines broke away from the right wing, the engine fue l
supply lines were ruptured . As no parts of the engine fuel shut of f
valves and the associated section of the right hand wing front spa r
were recovered, it could not be determined if the separation of th e
engines led to damage to the fuel shutoff valve actuator motors .
These are mounted on the front spar of the wing .
Damage to the fuel system piping could have resulted in loss of fue l
being pumped from the tank through the fuel manifolds and engin e
fuel shut off valve on the front wing spar .
1 .12 .3 .7 Damage to Fire Detection and Extinguishing System s
Damage to fire detection loops after engine separation resulte d
probably in electrical short cuts which caused fault-fault indication s
and subsequent fire warnings . Fire warning at engine
27
HYDRAULIC SYSTEM S
FUNCTIONAL
SYSTEM NO . 1
SYSTEM NO . 2
LOST
SYSTEM NO . 3
SYSTEM NO . 4
LEFT OUTBOARD AILERO N
LEFT OUTBOARD AILERO N
RIGHT OUTBOARD AILERO N
RIGHT OUTBOARD AILERO N
LEFT INBOARD AILERO N
RIGHT INBOARD AILERO N
LEFT INBOARD AILERO N
RIGHT INBOARD AILERO N
LEFT CENTRAL CONTRO L

ACTUATOR
LEFT CENTRAL CONTRO L

ACTUATO R
RIGHT CENTRAL CONTRO L

ACTUATO R
RIGHT CENTRAL CONTRO L

ACTUATO R
SPOILERS 2, 3, 10, 11
SPOILERS 1, 4, 9, 12
SPOILERS 5,
LEFT OUTBOARD ELEVATO R
LEFT OUTBOARD ELEVATO R
RIGHT OUTBOARD ELEVATO R
RIGHT OUTBOARD ELEVATO R
RIGHT INBOARD ELEVATOR
RIGHT INBOARD ELEVATO R
LEFT INBOARD ELEVATO R
LEFT INBOARD ELEVATOR
STABILIZER PITCH TRIM (*)

UPPER RUDDER
INBOARD
TE
LOWER RUDDER
FLAPS
TE
hcd$
RcLi e
YA W
LOWER RUDDER
OUTBOARD
FLAPS
FORWARD MAIN GEA R

ACTUATOR
AFT MAIN GEAR ACTUATO R
PITC H
(}kc)
STABILIZER PITCH TRIM

UPPER RUDDER
ROL L
FLA P
GEA R
NOSE GEAR ACTUATOR

SPOILERS
6, 7
GP, DUN D
NOSE GEAR STEERING

NORMAL BRAKES (SECONDARY)
RESERVE BRAKES
NORMAL BRAKES(PRIMARY)
USER S

no . 3 was reported by the flight crew . It is not known if the engine fir e
warning continued during the remainder of the flight nor if the bottl e
discharge light was illuminated in the cockpit .
1 .13
Medical and Pathological Informatio n
All pathological investigation was made for the purpose of identification .

1 .14
Fire
1 .14 .1
Fire on Board
Examination of the separated engines no . 3 and 4, their associate d

pylons and parts of the structure that broke off the aircraft at engin e
separation, did not show any signs of fire or soot .
After engine separation some witnesses reported a short, sparklik e
fire which extinguished shortly afterwards . No fire was noticed on th e
aircraft during its subsequent flight apart from two not confirme d
witness reports about fire just prior to impact .
1 .14 .2
Fire on the Groun d
Upon impact with the apartment buildings and the ground the aircraf
t
disintegrated . The spilled fuel resulted in explosion . Aircraft debri s
and burning fuel were thrown over an area of about 400 meters wid e
and 600 meters long . The burning fuel set fire to a number o f
adjacent apartments . Additional damage to the apartments occurred
because of the blast of the explosion . A large amount of the aircraf
t
wreckage was consumed by fire .
1 .14 .3
Fire Brigade Response on the Airport
The Airport fire brigade unit "Sloten" was told that a B747 was returning to Schiphol Airport with engine problems . The unit, consistin g
of three MAC 11 vehicles, one SAV vehicle and 11 firefighters, went t o
the readiness positions for Runway 06, the preferential landin g
runway . The unit was in position within one minute of notification .
When the message was received that El Al 1862 was intending to lan d
on Runway 27, the unit moved to the readiness positions for tha t
runway . After sighting a large fireball to the east the fire brigade uni t
was directed to the scene of the accident .
1 .14 .4
Fire Brigade Response Outside the Airpor t
Four airport fire brigade vehicles in coordination with the Amsterda m

City fire brigade started fire fighting activities after arriving at th e
scene of the accident .
The main fire was under control within several minutes, using foam .
1 .15
Survival Aspects
The accident was not survivable for the persons on board o f

El Al 1862 because of the impact forces and the ensuing explosio n
and fire .
1 .16
Tests and Researc h
Note: Test and research efforts were directed to investigate th e

recovered parts of the pylon . Only in a later stage of the investigatio n
it became clear that probably a not recovered part failed first .
29

1 .16 .1
Metallurgic Investigation of Outboard Midspar Fuse Pi n
At the accident site, a section of the outboard wing support fittin g

(inboard side only) was recovered with the central part of th e
outboard midspar fuse pin in place . The inboard fracture surfac e
failed in shear, while the outboard fracture surface exhibited signs o f
metal-fatigue .
The Dutch National Aerospace Laboratory was contracted to carr y
out a metallurgic investigation of the fuse pin . The results of thi s
investigation are contained in report CR 93030 C : "Investigation of th e
Outboard Midspar Fuse Pin from the Pylon of Engine #3 of El A l
1862" . The laboratory concluded the following :
1.
A large fatigue crack was present at the outboard location o f

minimum wall thickness of the fuse pin, which was of the "
bottle bore " configuration . This fatigue crack was up to 4
millimetre in depth and encompassed about 50 % of th e
inside circumference .
2.
The fatigue crack had developed from multiple initiatio n

sites along poor quality machining grooves . There was n o
evidence of corrosion pitting that could have contributed t o
fatigue initiation .
3.
The material of the fuse pin met the chemistry specificatio n

for 4330 M steel . However, hardness measurements indicated that the tensile strength was about 117 ksi, which i s
lower than the specified range of 126- 139 ksi .
It should be noted that a low hardness does not mean the pin wa s
understrength, because sometimes the final machine cut is adjuste d
based on the testing conducted in the sampling process .
Boeing also carried out a metallurgic investigation of the fuse pin .
The Boeing findings concur with the NLR findings .
Boeing was able to derive a crack growth curve of the fatigue fractur e
surface as a function of total airplane cycles (flight cycles) versu s
crack depth .
Based on this curve Boeing concludes that at the last inspection o f
the fuse pin, 257 flights before the accident flight, the fatigue crac k
would have had a depth of .14 inch . As the ultrasonic reference dept h
is .085 inch a detectable crack existed at the last inspection .
El Al however contests the Boeing findings regarding the crac k
growth data .
El Al is of the opinion that the redistribution of loads after the initia l
failure in the inboard midspar fitting lug resulted in a significant
increase in crack growth rate during a number of flights and that it i s
therefore conceivable that the crack was of less than detectabl e
length at the last ultrasonic inspection .
The NLR was requested to comment on this fundamental differenc e
of opinion between Boeing and El Al regarding the interpretation o f
the striation count of the fatigue crack in the outboard midspar fus e
pin .
The NLR concludes that : "The intermediate markings between 'heav y
striations' cannot be interpreted unambiguously" .
30
1 .16 .2
Metallurgic Investigation of Inboard Midspar Fitting Lu g
The inboard midspar fitting of pylon no . 3, with some attachmen t

structure, was recovered from the Gooimeer . The outboard lug of th e
clevis fitting had failed . The National Aerospace Laboratory was als o
contracted to examine this part and the results are contained in thei r
report CR 92454 C : "Investigation of the Inboard Midspar Fitting o f
Engine no . 3 of EI Al 1862" . The results of this investigation can b e
summarized as follows :
1.
In all probability the lug fractured and failed by overload ,

under a combination of bending and tensile loads . Th e
caveat "In all probability" is considered necessar y
because the fracture surface details had been almost
completely destroyed by corrosion, most probably as a
consequence of immersion in the water .
2.
Checks of the lug material, 4330 M low-alloy high-strengt h

steel showed that it met the requirements of hardness ,
tensile strength and chemistry . The steel microstructure wa s
also satisfactory .
Boeing also carried out a metallurgic investigation of the lug an d

came to the same conclusions as the Aerospace Laboratory, saying ,
"The lug fracture was determined to be ductile (i .e . no fatigue) an d
appears to have resulted from tension and to a lesser extent fro m
lateral bending . "
1 .16 .3
Bird Impac t
A detailed study into bird migration during the flight of the acciden t
aircraft was made by the expert of the Royal Netherlands Air Force .
The study revealed heavy bird migration in the Schiphol area durin g
the 14 minute flight of the aircraft, and birds could be found up to a n
altitude of 5,000 feet .
The chances of a bird impact were considered at its maximum jus t
after take off, and were estimated to be lower at the altitude of 6,00 0
feet and above .
Engines no . 3 and 4 and all the parts from the leading edge of th e
right hand wing were examined under ultraviolet light and via chemical tests . The internal and external examination of engine no . 3 and 4
and of the engine cowlings showed no evidence of bird impact .
Examination of variable camber flap 18 and two parts of the righ t
wing leading edge structure showed signs of possible bird impact ,
however, laboratory analysis could not determine whether th e
deposits on the parts were of animal nature . In some cases there wa s
not enough material to test, and in all cases, the parts had bee n
exposed to sunlight and water for a too long period of time .
Some bird feathers were found on a leading edge part that probabl y
belonged to the left wing . This part was found at the crash site .
Chemical analysis by the Zoological Institute of the University o f
Amsterdam confirmed that the remnants indicated a pigeon .
1 .16 .4
Sabotag e
A detailed investigation into the possibility of sabotage was performed . Details including the type of cargo, the dispatching of th e
airplane, various security aspects and general maintenance activitie s
were examined . The engines and pylons were visually inspected fo r
signs of high energy explosion or other sabotage .
Also, several airplane structural parts and foreign objects associated
31
with the wreckage were subjected to chemo analysis with negative

results . No evidence of sabotage was found .
1 .16 .5
Trajectory Engine No. 3
Boeing studied engine trajectories for a variety of fuse pin releas e

scenarios and thrust levels . The strut and engine were treated as rigi d
bodies, while the upper link and diagonal brace were modelled a s
beams . The midspar fuse pins and fittings were modelled as zer o
length springs . Dynamic loads noted during the release sequenc e
scenario 4 that more than one fitting would need to be belo w
strength for a pylon release to occur . The study indicated that most o f
the no . 3 pylon fuse pin release sequence scenarios resulted in th e
no . 3 engine striking the no . 4 engine, but not necessarily in the orien tation noted during the El Al accident .
The release sequence that came the closest to the El Al trajectory wa s
inboard midspar fitting failure, followed by outboard midspar fittin g
failure, upper link failure, and finally diagonal brace failure .
1 .17
Additional Informatio n
1 .17 .1
Other Related Incidents and Accident s
Below a summary is given of known accidents or incidents involvin g

pylon problems which occurred during the past years .
1.
December 27, 1979 . London Heathrow Airport . A B747-12 1

Freighter . During landing no . 4 pylon bulkhead began t o
break free of the pylon because of fatigue and other pre existing damage . The aircraft accumulated 43,615 hours an d
9,505 cycles .
2.
December 29, 1991 . Near Taipei, Taiwan . A B747-200 Freighter with P&W engines . During climbout passing 5,200 feet ,
engine/pylon combination no . 3 and 4 separated from th e
wing . The aircraft accumulated 45,868 hours and 9,094 fligh t
cycles . Preliminary investigation revealed that from pylo n
no . 3 both inboard midspar fitting lugs had failed, partly i n
fatigue and partly ductile . A section of the fuse pin of th e
outboard midspar fitting was also recovered but the fractur e
surface was ductile . Investigation still in progress .
3.
March 31, 1992 . Istres, France . A B707-321CH Freighter .

While climbing from FL 290 to FL 330, passing FL 320 wit h
280 knots engine/pylon combination no . 3 and 4 separate d
from the wing . Right wing on fire . A successful emergency
landing was carried out . Investigation revealed that the no . 3
engine/pylon combination separated first and hit the no . 4
engine, causing the separation of pylon no . 4 . The inboar d
midspar fitting lug of pylon no . 3 was broken due to fatigue .
4.
April 25, 1992 . Miami, Florida . A B707-324C . During take off

no . 3 engine/pylon combination separated from the wing .
The aircraft accumulated 53,257 hours and 20,399 fligh t
cycles . The investigation revealed the inboard midspa r
fitting of pylon no . 3 showed fatigue cracking .
5.
September 11, 1992 . A B747-200 standing on the apron .

Engine/pylon combination no . 3 was slightly droope d
inward and a 2 centimetre gap was noticeable between th e
strut and the aircraft's wing . Inspection revealed th e
outboard midspar fuse pin was broken and severely corroded in three places . The aircraft accumulated 42,106 hour s
and 9,176 flight cycles .
32
6.
October 8, 1992 . A B747-212B passenger aircraft . Visua l

inspections of the pylon wing attachment revealed a cracke d
inboard midspar fitting lug of pylon no . 3 with signs of
fatigue in a region of severe corrosion pitting in the bore o f
the lug . The aircraft accumulated 51,798 hours and 10,83 7
flight cycles .
7.
February 1, 1993 . A B747-212B passenger aircraft . Whil e

performing a corrosion check during a C-inspection, a crac k
was detected in the inboard lug of the inboard midspa r
fitting of pylon no . 3 .
Another crack was found in the forward lug of the diagona l
brace . The aircraft accumulated 49,908 hours and 10,58 0
flight cycles .
8.
March 31, 1993 . Anchorage, Alaska . A B747-121 Freighter .

During climbout passing 2,000 feet in turbulence ,
engine/pylon no . 2 separated from the wing . Despite havin g
severe control problems, the crew made a successfu l
emergency landing .
Preliminary investigation revealed that the engine/pylo n
combination separated from the wing because of structura l
overload . The leading edge between engines no . 1 and 2
was severely damaged . A three inch crack was found in a
thin web section between the pylon midspar attachmen t
fittings .
(Boeing indicated that the crack had sealant on it, meanin g
the crack would be there for a while) . The airplane accumulated 83,906 hours and 18,387 flight cycles .
After the EI Al accident the frequency of fuse pins inspection wa s

increased . Numerous reportings from operators regarding pylon wing attachment fitting problems were received . In most cases th e
reportings dealt with cracked fuse pins at different pylon-wing attach ment fitting locations .
Note: Occurrence numbers 3 and 4 were with B707's with hush kit s
installed . The existing B707 AD's are not adjusted to account for th e
difference in loads due to the installed hushkits .
1 .17 .2
Additional Investigatio n
After the first issue of the preliminary report several subjects wer e
investigated additionally .
By pure coincidence an aircraft spotter took some photographs of E l
Al 1862 when it arrived at Schiphol Airport on October 4, 1992 . O n
these photographs it appears that engine no 3 has an upward tilt i n
relation to the other three engines . The question arose whether thi s
upward tilt could have been caused by disconnections of the wing t o
strut attachments . Experts explained that a disconnection could not
possibly result in a tilt as shown on the photographs . Because a
transit maintenance check (including condition of engine and strut )
was properly carried out and also because the Board at this stage o f
the investigation became aware of the technical improbability tha t
pylon no .3 attachments had failed prior to the accident flight, furthe r
investigation on this subject was put aside .
Another subject of additional investigation was the question if th e
depleted uranium balance weights in the El Al Boeing represente d
potential health hazards . From the originally installed deplete d
uranium weights, two were replaced by Tungsten so not more tha n
400 kg . of depleted uranium was involved in the crash and the fire
33
after impact . A radiation expert of ECN (Netherlands Energy Researc h

Foundation) at Petten, stated that the low radioactivity of deplete d
uranium does not represent a real danger .
Although the material, being a heavy metal, is poisonous it can onl y
enter a human body in soluble state as uraniumoxide, as a dust or a s
a vapour . Disintegration to dust or vaporisation will not take place i n
a crash or the resulting fire .
The boiling point of depleted uranium (3813 C) exceeds the possibl e
temperature of a kerosine fire by far .
A third additional investigation concerned several transmission s
received by the Rescue Coordination Centre in Ijmuiden (RCC) fro m
yachts in or near the IJsselmeer harbour of Naarden on marifon e
channel 16 (for urgent and emergency naval communications) .
After the reception of reports that "
an aircraft had lost a part of a n
only one side of the engines was stil l
engine
" and that "
working
", RCC contacted ACC Schiphol by telephone . In thi s
telephone conversation RCC asked if it was known that an airplan e
was in trouble over the Hilversum/Naarden area . This was acknowledged by ACC and, on RCC's question if it was correct that an engin e
had separated, ACC answered that they did not known the exac t
".
details but that "
they are in contact with us anyhow
After the confirmation that the aircraft was still airborne and th e
" the conversation ended .
statement "
we know about it
During this telephone call RCC received a subsequent channel 1 6
that the aircraft was probably dumping fuel
" an d
report "
"
must have lost one or two of its engines
" and severa l
that the tw o
minutes later (a few seconds before impact) a report "
"
right hand engines are off and the two port engines are still on
RCC did not resume contact with ACC . Subsequently reports came i n
that the airplane had crashed and smoke was seen .
There has definitely been a misunderstanding between RCC and AC C
about the possibility of engine separation . The knowledge of RCC ,
however, at the time of the telephone call was not very precise, whic h
makes it understandable that they did not persist on the subject .
34
2 . ANALYSI S
2 .1
Genera l
The flightcrew was trained and certificated in accordance wit h

appropriate Israeli CAA, El Al and Industry standard requirement s
and procedures .
The airplane was inspected and maintained in accordance with El A l
and Boeing maintenance procedures .
Meteorological conditions and navigation and communication facilities did not contribute to the accident .
The Board determined that the accident sequence was initiated by th e
in-flight separation of the no . 3 engine pylon from the wing . Th e
Board's investigation examined the probable causes for this separation and the probable causes for the subsequent loss of control .
The Board's analysis of this accident included an evaluation of :
evidence to determine the initial failure origin ;
the design and certification of the fused pylon concept ;
the effectiveness of FAA's supervision on continuing airworthiness ;
performance of the flightcrew ;
- ATC services ;
actions taken since the accident .
2 .2
Engine Pylon Separatio n
At the time of the accident the airplane had a valid Certificate o f

Airworthiness . The maintenance transit check was properly carrie d
out at Schiphol Airport . No defects were recorded which could hav e
played a role in the accident .
External and internal examination of the engines showed that al l
damage was either a result of gyroscopic effects during pylon separation or the impact of engine no . 3 with engine no . 4 and/or the impac t
of the engines with the water . No physical evidence was found insid e
the engines indicating that a surge could have occurred . Also examination of the El Al maintenance records and DFDR data from befor e
the accident flight revealed no signs of surges .
The possibility of sabotage was examined by several police an d
security agencies familiar with sabotage techniques and terroris t
activity . No evidence of sabotage was found .
The Board therefore concluded that the separation of the engin e
pylon was caused by a failure of connecting components that attac h
the pylon to the wing of the airplane .
To determine the initial failure origin a total of 9 different scenario s
were identified each of which could lead to the separation of th e
engine pylon from the wing .
Separation Scenarios :
1.
2.
3.
4.
Upper link/pin fractured or disconnected first ;

Inboard midspar fitting/pin fractured or disconnected first ;
Outboard midspar fitting/pin fractured or disconnected first ;
Simultaneous fracture or disconnection of both the inboard an d
outboard midspar fitting/pins ;
5. Diagonal brace/pin fractured or disconnected first ;
35
6.
7.
8.
9.
Massive static overload occurred ;

Bird impact occurred ;
Engine seizure occurred ;
Side brace fractured or disconnected first .
Scenarios 4 through 9 were eliminated as viable options . The reason s

are summarized below :
Scenario 4 :
Scenario 5 :
Scenario 6 :
Scenario 7 :
Scenario 8 :
Scenario 9 :
only a large overload in lateral direction could hav e

caused this type of failure . There was no evidence o n
the DFDR that any unusual load occurred .
examination of the diagonal brace and its attachment s
indicate that the disconnection was due to overload at
engine separation .
there was no indication of any unusual loading on th e
DFDR .
no evidence of foreign object damage, e .g . bir d
impact, to the engine prior to the separation wa s
found .
examination of the engine indicated that the fan wa s
rotating at the time of separation, therefore no engin e
seizure could have occurred .
examination of the side brace and its attachmen t
indicated that the disconnection was due to a n
overload at engine separation .
As the upper part of the upper link and corresponding fitting was no t
recovered the question arose whether or not this link was properl y
attached at the time of the separation . By means of a stress analysis it
was shown that the fracture of the upper link in the note d
bending/torsion mode could only have occurred if the wing-end pi n
was in place and intact . Scenario 1 could therefore be eliminated .
The elimination process resulted thus in two possible remainin g
scenarios . The approach taken for the further evaluation of thes e
scenarios was mainly one of deduction, augmented with stress an d
load analysis . Using this approach it could be proven that a separation initiated by a failure in the outboard midspar fitting was highl y
improbable .
The inboard midspar fitting was recovered . The outboard lug of th e
fitting had fractured with 150 degrees segment of the lug missing .
The lug fracture was determined to be ductile (i .e . no fatigue) an d
appeared to have resulted primarily from tension and to a lesse r
extent from lateral bending . The ductile failure can only be explaine d
if it was eccentrically loaded . For this to occur the inboard shear fac e
of the fuse pin must have sheared first in order to subject the lug t o
an eccentric load .
36
WING LOWER SURFAC E

FOU R
~~~~
TWO
N`..~~\ N. Alp
INBOAR D
MIDSPAR
STRUT NO . 3
FRACTURE DETAI L
AND SEQUENCE
C~
INB D
VIEW LOOKING FORWARD
<2 )
THRE E
OUTBOAR D
MIDSPA R
As there is no in service evidence that the EI Al airplane experience d

a static overload preceding the accident it is assumed that th e
inboard shear face of the fuse pin was initially fatigued and the n
failed under normal flight conditions .
Based on this assumption separation scenario 2 was further developed with regard to the question whether the failure did occur befor e
the fatal flight or during this flight .
Figure 6 shows pylon no . 3 fracture details for scenario 2 and th e
sequence of each fracture in time numbered 1, 2, 3 and 4 .
By applying the methodology as explained above, it can be prove n
that a fracture of the inboard fuse pin before the start of the flight ou t
of Schiphol Airport is highly improbable . The load carrying capability
of the remaining structural elements, taking into account dynami c
effects, is sufficient to carry the redistributed loads .
Therefore the scenario which is most likely, is (1) a fracture initiate d
by a fatigue crack of the shear face of the inboard midspar fuse pin .
This was followed by (2) a sequential failure of the outboard lug o f
the inboard midspar fitting . Then (3) the outboard shear face . Finall y
(4) the inboard shear face of the outboard midspar fuse pin . Th e
subsequent pylon engine separation occurred during the flight out o f
Schiphol Airport at 6500 feet and at an IAS of 267 knots .
2 .3
Design and Certification Assessmen t
As outlined in paragraph 1 .6 .3 .1 the pylon is designed to brea k

cleanly away from the wing .
The certification basis of the Boeing 747 includes a Fatigue Evaluatio n
of Flight Structure as laid down by FAR part 25 .571 Am .8 . This evaluation requires that :
"Those parts of the structure (including wings, fixed an d
movable control surfaces, the fuselage and their relate d
primary attachments), whose failure could result i n
catastrophic failure of the airplane, must be evaluated unde r
the provisions of either paragraph (b), Fatigue Strength, o r
(c), Fail-safe Strength of this section . "
Based on the similar fuse pin design of the Boeing 707, Boein g
concluded that the fused pylon concept effectively protected win g
structure and fuel tanks against consequences of pylon overloads . A
detailed fail-safe analysis of this nacelle and pylon concept was mad e
by Boeing . This analysis addressed all critical load conditions reslting from abnormal flight or landing conditions .
It should be noted that the report does not address the specific fail safe load analysis assuming a fatigue failure or obvious partial failur e
of a single principle structural element .
It is important to note that during type certification a then state-of the-art fatigue analysis of the pylon structure was performed b y
Boeing in order to establish the maintenance requirements for th e
Boeing 747 . In real life this did not turn out to be sufficiently reliable .
At that time full scale testing was not part of the USA airplane certification process .
Boeing did not conduct any structural testing of the pylon to positively determine its static strength, fatigue and fail-safe characteristics .
The FAA accepted Boeing's contention that since the Boeing 70 7
pylon had proved reliable, the nearly identical design of the Boein g
747 pylon would also be reliable . Therefore on the date of type certifi 38

cation the nacelle and pylon design met all applicable airworthines s
requirements .
The supervision of the continued airworthiness of the Boeing 74 7
type design is a responsibility of the FAA . This organization carrie s
out its responsibility mainly by issuing Airworthiness Directives ,
many of which were originally Boeing Service Bulletins . In case of th e
Boeing 747 the FAA issued a large number of AD's addressin g
numerous fatigue problems in the pylon structure, including fus e
pins, lugs and fittings . Nevertheless, new cracks and failures wer e
discovered frequently, giving doubt about the ultimate strength o f
the structure .
In addition to the fatigue problems, a static problem was identified i n
service . On several occasions so-called crank-shafting of fuse pin s
was reported . Apparently a plastic deformation of the fuse pins ca n
occur at operational load conditions .
Over a time period of 15 months three pylons (China Airlines, El A I
and Evergreen) have failed in flight, resulting in two fatal and on e
serious accident .
The original design together with the continuous airworthines s
measures and the associated inspection system did not guarante e
the minimum required level of safety of the Boeing 747 at the time o f
the accident.
2 .4
Final loss of Contro l
The analysis concerns the controllability and performance aspects o f

the airplane .
2 .4 .1
Controllability
Assuming a fixed rudder deflection an increase in thrust asymmetr y

generates a yaw, resulting in a sideslip which in turn induces a rol l
moment . These motions can be controlled by:
- a rudder deflection to stop the yaw ;
- a lateral control deflection to stop the roll ;
- a thrust reduction .
Loss of part of the leading edge flaps and damage of the right win g
results in a change in lift generating capability of that wing . At smal l
angles of attack the lift on both wings is essentially equal, at highe r
angles of attack the increase of lift on the damaged wing is less tha n
the increase in lift on the undamaged wing . An increase in angle o f
attack will therefore generate a roll moment . In the case of El Al 186 2
this increase caused bank steepening during the right turns in th e
direction of the damaged wing . This effect was confirmed by DFD R
data .
In general modern airplanes have adequate control capability to tur n
in either direction in a two engine inoperative situation .
However turning into the direction of the functioning engines wil l
create a flight condition with more margin . It is recommended to
emphasize this basic knowledge during training .
2 .4 .2
Performance
An energy analysis was performed based upon altitude and airspee d

data from the DFDR . It should be realised that this method does no t
allow extrapolation of performance capabilities in other condition s
then those encountered during this flight . Based on this analysis th e
following conclusions can be made :
39
- Marginal level flight capability was available at 270 knots and go around power with a limited manoeuvring capability ;
- At MCT thrust and 270 knots IAS there was no level flight capability ;
- Performance degraded below about 260 knots at increased angle s
of attack . Deceleration to 256 knots resulted in a considerable sin k
rate .
It is therefore believed that the performance deterioration at increased angles of attack is the most likely explanation for the advance ment of the throttles during the final stage of the flight .
2 .4 .3
Synthesis
After separation of the engines and pylons the crew flew the aircraft
in the following condition :
1.
2.
3.
4.
7.
8.
9.
RH wing leading edge severely damaged .

RH wing leading edge flaps partly lost .
RH outboard aileron floating at 5 degrees trailing edge up .
limited roll control due to :

- no outboard aileron available ;
- spoiler system partly available .
limited rudder control due to lagging behind of lower rudde r
for unknown reasons .
RH inboard aileron probably less effective due to disturbe d
airflow created by damage of the wing leading edge an d
loss of pylon no . 3 .
engine no . 1 and 2 at high thrust settings .
Until the last phase of the flight aircraft control was possible but
extremely difficult . The aircraft was in a right turn to intercept th e
localizer and the crew was preparing for the final approach and ma y
have selected the leading edge flaps electrically . During the last
minute the following occurred as can be derived from DFDR data . Th e
aircraft decelerated when the pitch attitude was increased probabl y
to reduce the rate of descent .
The associated increase in angle of attack caused an increased drag .
Additional drag of a sideslip and possible extended leading edg e
flaps resulted in a further speed decay . This speed decay was proba bly the reason to increase thrust on the two remaining engines no . 1
and 2 .
All this generated an increased roll moment to the right by :
1.
asymmetric lift generation at increased angle of attac k
2.
high thrust asymmetry
3.
loss of aerodynamic efficiency of the RH inboard aileron a t
increased angle of attac k
4.
possible asymmetric lift due to leading edge flaps operation .
The resulting roll moment exceeded the available roll control .
Near the end of the flight the crew was clearly confronted with a
dilemma . On the one hand they needed extra thrust to decrease th e
rate of descend and maintain speed, on the other hand the highe r
thrust increased the control difficulties . In general, in case of degraded performance, thrust should be confined to that level at whic h
aircraft control can be maintained .
2 .5
Performance of the Flight Cre w
This part of the investigation was hampered by the lack of CVR infor-
40
mation . Apart from the available factual information, deductio n

based on general airline flying knowledge and Boeing 747 flyin g
experience was used to achieve a best estimate of what happened i n
the cockpit after engine separation .
The DFDR revealed that during the manoeuvring of the airplane th e
limited availability of the flight controls obliged the captain to use u p
to full rudder pedal deflection and various control wheel deflection s
between 20 and 60 degrees to the left .
The Boeing training manual states that in an asymmetric flight condition with two engines inoperative on one side there should b e
enough rudder authority to allow the control wheel to be almos t
neutral up to MCT at manoeuvring speed .
During investigation in the Boeing simulator it was noted that wit h
flaps up (which locks out the outboard ailerons) under the abov e
mentioned conditions and with maximum rudder deflection appr . 3 0
degrees left wing down control wheel deflection was needed t o
maintain straight flight .
In the case of El AI 1862 the damage to the right wing and the upflo ating right outboard aileron required even more left wing dow n
control wheel deflection . This can be observed on the DFDR and wa s
also noticed during simulator investigation .
This supports the hypothesis that the crew faced a very unusua l
situation . At 260 knots the airplane was almost out of control with ful l
deflected rudder and 60 to 70% of maximum lateral control . This wa s
very different from what the crew would expect from their knowledg e
of and experience with an aircraft with two engines inoperative .
When El Al 1862 departed from Schiphol Airport the captain was th e

pilot not flying (PNF) and was identified communicating with ATC
until the moment that engines no . 3 and 4 separated from the righ t
wing . The "mayday" call and the following radiocommunicatio n
were identified as being done by the first officer . The captain clearl y
took over control and kept control of the airplane throughout th e
remainder of the flight .
With respect to resource management at the flightdeck the Board i s
of the opinion that in general the captain is in a better (management )
position when he can leave or delegate control of the airplane to a
fully qualified first officer .
Given the severe controllability problems the Board respects th e
decision of the captain to take over control despite the fact that th e
first officer was fully qualified . The Board also realizes that th e
situation did not stabilize in such a way that the captain could reason ably return control to first officer .
Within one minute after engine separation the crew decided to retur n
immediately and to land on runway 27, in spite of the unfavourabl e
wind conditions for this runway . The crew may have been urged t o
this decision for the following reasons :
- the possibility of having been hit by a missile causing a quickl y
deteriorating situation ;
- the believe that they were experiencing one or two uncontrollabl e
engine fires with the possibility that these fire(s) would burn int o
the wing ;
- the assumption that the airplane was too heavy to maintai n
straight and level flight;
- the crew was familiar with Schiphol Airport, knew the lay-out of th e
runways and knew that runway 27 was the longest and the neares t
available runway .
41
The captain's decision to land on runway 27, despite the fact that thi s
was not the runway in use, was an understandable decision unde r
the circumstances .
The decision to land as soon as possible committed the crew t o
perform under extreme time constrains . The complexity of th e
emergency on the other hand called for time consuming and partl y
conflicting checklist procedures . Warnings and indications in th e
cockpit were most likely compelling and confusing . Furthermore th e
pilots were confronted with a controllability and performanc e
situation which was completely unknown to them and they were no t
in a position to make a correct assessment . The Board is of th e
opinion that given the situation of the crew as described above an d
the marginal controllability the possibility for a safe landing wa s
highly improbable, if not virtually impossible .
2 .6
ATC Performanc e
Although Air Traffic Control was not a contributing factor to th e

accident the Board believes that improvements can be made wit h
regard to the handling of in-flight emergencies .
The exchange of information was at times inadequate . The crew onl y
gave sparse information concerning their problems and intentions .
The controller occasionally used nonstandard phraseology whic h
was not as explicit or understandable as would be desirable in a n
emergency situation . In these situations crews most certainly ar e
working under extreme workload conditions and the controllers ma y
feel reluctant to interfere with a crew involved in an emergenc y
situation . However pilots and ATC personnel should be aware that fo r
the adequate handling of an emergency it is vital to use standar d
phraseology and to exchange all necessary information about th e
urgency and the severity of the situation .
ATC was confronted with the unexpected intention of the crew t o
land on runway 27 instead of the runway in use (runway 06), th e
runway to which the crew initially was directed . The attempt of th e
controller to position the airplane by radar vectoring to a point 12 N M
on the localizer for runway 27 was not completely successful .
A wider than normal set-up of the circuit would have better allowe d
for the possible steering errors and slow reactions to headin g
changes which occurred and which may be expected in emergenc y
situations .
During the procedure to vector the airplane for runway 27 it flew ove r
the city of Amsterdam . The Board is fully aware of the responsibilit y
and authority of the captain of an airplane in distress . The Board als o
realizes that after the declaration of an emergency ATC recognizes a s
its main task, the assistance of the crew in its efforts to recover th e
airplane .
However, the Board feels that in the handling of emergenc y
situations not only the safety of airplane and passengers but also th e
possible risk to third parties should be taken into account .
Information regarding the separation of both engines no . 3 and 4 di d
not reach the ATC controllers concerned with the emergency and wa s
therefore not relayed to the crew .
Although it remains questionable if, when relayed, this knowledg e
would have changed the course of events, it could have given th e
crew at least a better understanding of the unusual situation .
42
2 .7
Actions Taken Since the Acciden t
When it became evident that also the "bulkhead style" fuse pin wa s
not only prone to corrosion but also cracked under service conditions, Boeing decided in November 1992 to develop a new design o f
the fuse pin taking into account the following design objectives :
static strength should be increased to such a level that the desig n
loads for abnormal flight conditions could be met without a failure
of the fuse pin . However, in case of wheels-up landing the win g
should not be damaged in order to prevent fuel spillage ;
the fatigue life and crack growth life should be increased to such a
value that fatigue cracking should not occur throughout the life o f
the airplane and inspection intervals should be sufficiently long ;
- the new fuse pin should not be prone to any corrosion in order t o
fulfil the fatigue life objective ;
the manufacturing process should be easy to control and not resul t
in, for example, tooling marks which could initiate fatigue cracking .
Based on the above listed design requirements Boeing developed a
stainless steel fuse pin with a considerably improved fatigue an d
crack growth life . Furthermore the static strength and fatigue an d
crack growth analysis will be supported by tests .
When the inboard midspar fitting of the China Airlines Boeing 747
was recovered it became evident that both lugs had failed due t o
fatigue and after assessing the damage to the wing leading edge o f
the Evergreen Boeing 747 caused by the separation of engine no . 2 ,
Boeing decided that the Boeing 747 should meet the fail-safe requirements with respect to pylon-to-wing attachment .
As a consequence Boeing re-assessed the current pylon design i n
order to meet the fail-safe requirements . The hardware fix currentl y
proposed by Boeing will add an additional link to the midspa r
mounting in order to meet the fail-safe requirements . Extensive loca l
redesign of the pylon structure should eliminate most of the currentl y
effective inspections . The diagonal brace and upper link will be
replaced by designs with a higher load carrying capability .
The Board is of the opinion that :
- a full scale test should be carried out for the redesigned pylon t o
qualify static, fatigue and fail safe characteristics ;
- an extensive flight load measurement program involving revenu e
flights should be accomplished in order to gain a better knowledg e
of the actual loads on the pylon structure .
Boeing's intended modification program will probably start some where in the second quarter of 1994 and will require somewher e
between 12 and 17 days down time and about 10 .000 man hours pe r
airplane . Total time to modify all Boeing 747 airplanes will be 5 to 7
years .
In the interim, safety of the fleet of not yet modified airplanes will b e
guaranteed by :
- new stainless steel fuse pins ;
- adapted inspection program for the lugs ;
- use of a newly developed ultrasonic sensor, able to detect smalle r
cracks .
43
3 CONCLUSION S
3.1
Findings
1.
The airplane was inspected and maintained in accordanc e

with El Al and Boeing maintenance procedures .
2.
The flight crew was trained and certificated in accordanc e

with appropriate Israeli CAA, El Al, and industry standard
procedures .
3.
At an altitude of about 6,500 feet the no . 3 pylon failed, thi s

pylon and no . 3 engine separated from the right wing .
4.
The no . 3 engine struck the no . 4 engine, causing th e

- no . 4 pylon and engine to separate from the wing .
5.
The leading edge flaps and a portion of the fixed leadin g

edge of the wing back to the front spar were extensivel y
damaged . The no . 3 and 4 hydraulic systems were comple tely and the pneumatic system was partially disabled .
6.
The flight crew reported a fire on the no . 3 engine to ATC .

Given the system logic a fire warning may have been th e
result of a double fault indication of the system .
7.
Due to the limited field of view from the cockpit to the win g
area the flight crew was not able to observe the separatio n
of the no . 3 engine nor the damage to the wing .
8.
Performance and controllability were so severely limite d

that the airplane was marginally flyable .
9.
Current standard industry training requirements and procedures do not cover complex emergencies like encountere d
by El Al 1862 .
10.
After declaring an inflight emergency, the flight cre w

decided to return to Schiphol Airport immediately and lan d
on runway 27, although runway 06 was in use for landing .
11.
Because the airplane became too high and too close to th e

airport to accomplish a straight-in landing, the flight cre w
was vectored through an approximate 360 degree pattern o f
descending turns to intercept the final approach course .
12.
During the vectoring to the final approach, the flight cre w

stated to air traffic control that they were experiencin g
problems with the aircraft's flaps . Shortly before intercepting the final approach they reported controlling problems .
13.
During preparation for final approach speed reduction mad e

the airplane exceed the limits of its remaining contro l
capability . The airplane crashed into an apartment complex .
14.
Exchange of information between El Al 1862 and ATC wa s

not always adequate .
15.
The effectiveness of the fused pylon concept in protectin g

the wing structure and fuel tanks against the consequence s
of pylon overloads was based on the history of the simila r
fuse-pin design of the Boeing 707 .
45
16.
Certification of the B 747 pylon included a fail-safe analysi s

of the nacelle and pylon concept . At that time this analysi s
however did not address the specific fail-safe requiremen t
assuming a fatigue failure or partial failure of a single structural element .
17.
A then state-of-the-art fatigue analysis of the pylon structur e

was made to establish the maintenance requirements . I n
real life this did not turn out to be sufficiently reliable . Fro m
August 1979 on a large number of S .B .'s and A .D .'s wer e
issued addressing numerous fatigue problems in the pylo n
structure including fuse-pins, lugs and fittings .
18.
Inspection and analysis performed by specialists o n

recovered vital parts of the pylon construction reveale d
severe damage due to fatigue .
19.
No firm conclusion could be drawn whether or not th e

fatigue crack in the outboard midspar fuse pin was detectable at the last ultrasonic inspection .
20.
After analysing the possibilities it is assumed that th e

separation was initiated by a fatigue crack in the inboar d
shear face of the fuse-pin in the inboard midspar fitting .
21.
Over a period of 15 months, three pylons have failed i n

flight, resulting in two fatal and one serious accident . Th e
original type design together with the continuous airworthiness measures and associated inspection system did not
guarantee the minimum required level of safety of th e
Boeing 747 .
3 .2
Probable Cause s
The design and certification of the B 747 pylon was found to be inadequate to provide the required level of safety . Furthermore the syste m
to ensure structural integrity by inspection failed . This ultimatel y
caused - probably initiated by fatigue in the inboard midspar fuse-pi n
- the no . 3 pylon and engine to separate from the wing in such a wa y
that the no . 4 pylon and engine were torn off, part of the leadin g
edge of the wing was damaged and the use of several systems wa s
lost or limited .
This subsequently left the flight crew with very limited control of th e
airplane . Because of the marginal controllability a safe landin g
became highly improbable, if not virtually impossible .
46
4 RECOMMENDATION S
4 .1
Redesign the B747 pylon structure including attachment t o

engine and wing . All SB's and AD's should be terminate d
after the redesign .
4 .2
The redesign program for the pylon should include a ful l

scale fatigue and failsafe test .
4 .3
A large scale inflight fleet-wide fatigue load measuremen t

program should be carried out, both on wing, fuselage, an d
fin mounted engines in order to establish more realistic loa d
spectra for fatigue evaluations .
4 .4 Review present methods of controlling structural integrity ,

such as non destructive inspection techniques and airworthiness directive requirements, in the current design B74 7
pylon assembly .
4 .5
If a structural design concept is used as the basis for th e

certification of another design, in-service safety problem s
for both designs should be cross-referenced .
4 .6
Evaluate and where necessary improve the training an d

knowledge of flight crews concerning factors affectin g
aircraft control when flying in asymmetrical conditions suc h
as with one or more engines inoperative including :
- advantages and disadvantages of direction of tur n
- limitation of bank;
- use of thrust in order to maintain controllability ;
4 .7
Evaluate and where necessary improve the training an d

knowledge of flight crews in cockpit resource managemen t
in order to prepare them for multiple systems failures ,
conflicting checklist requirements and other beyond abnormal situations .
4 .8
Expand the information on inflight emergencies in appropriate guidance material to include advice how to insure tha t
pilots and air traffic controllers are aware of the importanc e
to exchange information in case of inflight emergencies . Th e
use of standard phraseology should be emphasized .
4 .9
Evaluate and where necessary develop common guideline s

on emergency procedures and phraseology to be use d
between ATC, Fire Brigade, Airport Authorities and RCC .
4 .10 Expand the training of pilots and ATC personnel to includ e

the awareness that in the handling of emergency situation s
not only the safety of airplane/passengers but also the ris k
to third parties especially residential areas should be consi dered .
47
4 .11
Review design philosophy of fire warning systems, t o

preclude false warnings upon engine separation .
4 .12
Review flight control design to ensure that flight contro l

surfaces do not contribute adversely to airplane control i n
case of loss of power to a control surface .
4 .13
Fire resistance of DFDR and CVR should be improved .
4.14
Investigate the advantages of installation cameras fo r

external inspection of the airplane from the flightdeck .
48
APPENDIXES
APPENDIX 1
MAIN IMPACT ARE A
SEEN AGAINST IMPACT DIRECTION
APPENDIX 2 . 1
DESCRIPTION OF THE WRECKAGE AREA AFTER ENGINE SEPARATIO N
The knowledge that engine 3 and 4 separated from th e
aircraft and the position thereof was mainly obtained b y
eye witnesses and was later confirmed by data of th e
radio communication with the aircraft .
Engine 4 was recovered on 4 October 1992, engine 3 on 1 4
October 1992 .
The area North of the "Hollandse Brug" and to the Sout h
till Naarden Harbour were extensively searched b y
specialised salvage vessels of the Netherlands Royal Nav y
A .O . the "Serberus" and the "Nautilus", making use o f
sonar and skindivers, more over by patrol vessels of the State Water Police, a
survey vessel of the Min . of Waterregulation with sona r
equipment and a private company (B .T .S) with specialise d
equipment for salvages .
The entire area under the flight path, both over wate r
and land, was intensively searched by the members of th e
Accident Investigation Bureau by means of the helicopte r
of the State Air Police .
By helicopter an oil slick was observed West of Pampus ,
several days after the accident . A vessel wit h
experimental equipment for underwater metal detectio n
searched the sea bottom over the area for 3 days, yet t o
no avail . The source of the oil slick stopped ventin g
after a day and no metal or clue was found as to th e
determination whether it had any relation to the air craft .
On the map the overall positions are indicated of th e
main wreckage parts . Numerous small parts that wer e
picked up by civilians and handed over to the loca l
police are not indicated .
They contained no significant technical information .
POSITION OF RECOVERED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
PARTS (See attached map )
Engine no . 4, with pylon and cowling parts of no . 4

Engine no . 3, with pylon and cowling parts of no . 3 an d
4, parts of fanblades of no . 4
Diagonal brace no . 3
Diagonal brace no . 4
Spinner no . 4
Part of tailcone no . 3
Tip of tailcone no . 3
Reverser screen part s
Cowling parts no . 3
Cowling part s
Part wing leading edg e
Leading edge flap no . 18 (RH wing) and flapdriv e
Air driven pump no . 3 and 4
Rear part of pylon no . 4
Pneumatic system bleed air pipe (near Muiden ,
not on the map )
Scattered over the area : small parts of honeycomb material o f

cowling no . 4 and parts of leading edge panels and structur e
of the RH wing
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WRECKAGE DISTRIBUTION CHART

ACCIDENT ELAL 4X-AXG 4-10-1992
APPENDIX 2.2
DESCRIPTION OF THE MAIN IMPACT AREA
1.
The aircraft 4X-AXG, ELAL flight 1862 crashed into th e

joint pex of the eleven story buildings "Kruitberg" an d
"Groeneveen", (see the picture in appendix 1), in th e
suburb "Bijlmermeer", Amsterdam South East, at a
distance of approx . 13 km from the threshold of Runwa y
27 of Schiphol Airport . The impact direction wa s
generally East .
- The initial impact area in the frontal face of th e
buildings was small . Pavement and walkways along th e
initial impact area and rather high trees immediatel y
in front of the building remained undamaged . Most o f
the structure in front of the wings of the aircraf t
was recovered from this area .
- After penetration of the heavy parts of the centr e
section and empennage through the blocks these an d
associated parts came to rest immediately behind th e
blocks, the scatter pattern was longest at this side .
On impact an explosion of the fuel scorched th e
facades of the blocks over a wide area .
The scatter pattern amounted roughly 400 meters wid e
and 600 meter long, the engines 1 and 2 and ski n
panels of the left hand wing being the farthest in th e
trail .
Parts of the cockpit section, cockpit interior ,
controls and human remains of the crew were recovere d
at the right hand side of the apex . On the map the
distribution of the principal wreckage parts is given .
- From the above data, it could be derived that th e
aircraft impacted with a very high vertical componen t
with only a slight horizontal displacement .
The aircraft collided with the buildings in a stee p
flightpath angle, a bank angle of slightly over 90 t o
the right and a nose down attitude of approx . 70 . Th e
configuration could not be established at the scene o f
the accident and could only be confirmed afte r
detailed inspection of the various parts an d
remainders there of .
- The aircraft was demolished completely, the majorit y

of the fragments consisted of small parts . The
wreckage parts penetrated deeply into the ground a t
the rear side of the blocks, piles of debris wer e
mixed with heavy parts of building structure, hous e
hold items, all initially fiercely burning .
- Ground water level, mud and locally repeatedly ensuin g
fires formed generally hazardous conditions, seriousl y
impairing the possibility of retrieving the fligh t
recorders, which were not found in the main wreckag e
area .
The DFDR was recovered after a scrutinous inspectio n
of the already removed mixture of debris of the
aircraft and rubble .
The possibility has to be considered seriously tha t
the CVR was stolen from the area, as were severa l
other parts, a .o . the left hand steering wheel .
- The initial salvage operation lasted far about one an d
a half week . The removal of the rubble was done by al l
sorts of lifting, excavation and removal equipment ,
frequently interrupted when local fires ensued o r
excavation of human remains prevailed . Local fires
revived for three days .
- The survey of the main wreckage area for the purpos e
of accident investigation was done by the members o f
the Accident Investigation Bureau assisted by th e
State Air Police and members of the various division s
of the Netherlands DGAC .
WRECKAGE DISTRIBUTIO N
MAIN IMPACT ARE A
(See attached map )
1.
Blue part of fi n
2.
Blue part of fi n
3.
Part bottom skin L .H .
4.
Part L .H .
5.
Maingear whee l
6.
Wingskin stringe r
7.
Part
8.
Wingskin stringers and part engine cowlin g
9.
Part engine hot section, wingskin,
wing, approx . 8 meters lon g
wingski n
L .H . wingski n
boosterpump, part o f
pylon, engine cowlin g

10.
Engine pylo n
11.
Part wingski n
12.
Part engine Jetpip e
13.
Part bottom skin L .H .
14.
Part engine pylon, with part of engine mounting and part o f
wing with, fuel
boosterpum p
engin e
Parts wingski n
15.
Part wingski n
16.
Engine cowlin g
17.
Part of wing and fairin g
18.
Part wingskin with fuel tank access panel s
19.
Engine con e
20.
Engine inlet cowlin g
21.
Blue part of fin and fairin g
22.
Part L .E . flap and engine cone attachmen t
23.
Freight containe r
24.
Part stabilizer . Engines 1 and 2
25.
Undercarriage beam . Parts main gea r
26.
Tailsection with APU and flight control s
27.
Parts maingear (wing and body )

Wing centersectio n
28.
Engine cowlin g
29.
Main gear doo r
30.
Part rudder
31.
Pylon with engine casin g
32.
Parts tailsectio n
33.
Main gear door and fuselage part s
34.
Parts R .H . win g
35.
Parts
L .H . wing, parts fin and stabilizer
WRECKAGE DISTRIBUTION CHAR T

ACCIDENT ELAL 4X-AXG 4-10-1992
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RECONSTRUCTED FLIGHTPAT H
a :.
EL AL FLIGHT 1862
OCTOBER 4, 199 2
MAIN CHART NOT REVISES SINCE 1 98 9

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g A/
N.
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APPENDIX 4. 1
TRANSCRIPT OF ATC RADIO AND TELEPHONE COMMUNICATION
Tine :
Fro' -
IOTCI
To
Sd =
Schiphol
SOCIC D
Cc =
Schiphol
Ground
Schiphol Tover
Belie
El Al
1862
Schiphol
Approach
lr
Schiphol
Arrival
ACC Controller sector 2
Tine :
Fro' -
To =
ICC Planoer sector
(OTC)
To
It =
Assistnut Tove r
lp =
Assistent Approach
conpany and
Fire-brigade
telephony
Aa
Airport Operations Doty Inner
Begin
_=
Interference audible in radio
tod
1=
- Sd
110211
Schiphol,
EI
the
investigation-lean
Sd - E
El
ot
110221
of
- Sd
AI
1661,
roger
20,
De
. . ehu
ruorap
clearance
..
OIL,
Other relevant air-traffic ;

telephony desi gnator of
the radio
the airlin e
Tine :
Fro' -
(OTC)
To
IOZ 081192,
2 novenber 199 2
the pronunciation in radio
111T :) :
ILK
ILK 11/t :
Ell =
ter Liogas
!LAI
IBC =
Iberia
DUI =
Lufthansa
811 =
Iritish lirvays
!LC =
ILA Cityhopper
(1/T :
(1/T :
lilt :
lote : At sole places

replaced by
' (nanel',
the privacy of
Shaerock)
1IAISCIIPT OF FL161 1
legio
Iberia )
EL IL 1162
Lottbansal
(11T : Speedbird )
01 OCTOIEI IT1 199 1
11/T : City)
the ori g inal
text
is
End
this to safeguar d
3OZIAG!
the people concerned
iafor l
staodDy
you
shor t
bare a
slo t
to Ben Gorion, Paepus -
hoger,
El
dl
1861,
clearance
on, Paspas departure,
Sd -
110214
110236
good evening,
End
the
departure, squavk 216 0
110210
110211
1862,
cation tango, IFl to Tel Aviv
ly, it rill
110225
Al
To
Inspection Directorate
110209
Fron
MCI
Translation
In italics - Text proposed by
telephony coenonications
110202
Tile :
Begin
End
Correct El Al
1861,
to Beu Guri
to sgoark 216 0
call you back fo r
start op on this, staodD y

E
- Si
(..
- Sd
Schiphol,
Onreadable
. .I
110111
110401
110412
110414
Si - E
El
II 1162,
the south
110420
110411
El Al
1862
..
eh
..
re request
nay
posh-back fro' our stai d
veil
so
taxivay to OIL,
- Sd
loger,
Sd
- E
El Al 1862,
you
..
eh
..
..
eh
. .
rather shor t
it's
taxi vi a
standb y
standing b y
110422
110540
110545
110545
your
posh-back ou
- Sd
Shah',
start-up is approved
121 .1,
oor ,
shaloa
thank yo u
110546
--a
110601
- Cc
Ground,
El
noon, eh . .
110611
110614
110615
M.
Al
eb
..
1862, good after-
freight
. .
..
el . . noeber
an d
request push-bac k
Sc
1862,
posh-back approve d
101 013192
110616
- Cc
Tint yo u
- Cc
El II
1862 ready for tax i
El II
1862 taxi
11061 6
111324
17132 6
171321
Cc - E
111334
111736
OIL,
via the sontb and fi t
is behind the Saab at your eleyev o'cloc k
- Gc
loger, behind
the Saab . .
eh
. .
01 L
171339
171134
Cc - E
111137
111737
El 11
1862 contact
Tover os 118 .1,
good -
by e
- Cc
Good da y
- T
El
- E
Good eyeoing El 11
111138
111804
Il 1862,
good
eyeoio g
111806
111806
171811
1862,
line-np
in se -
game OI L
111810
- 1
Roge r
- T
E1 11
- E
thin
- T
tiger
- E
El II
- T
Cleared
- E
lage r
- T
El 11
- E
Bye bye El
- T
Good da y
- 1
0epartare, El
17181 1
171911
1862, can ve Noe-up ?
17191 3
171914
sir,
line-op
01 L
17191 5
171916
11191 6
172049
1862 is cleared tale-off
OI L
11205 3
172051
for take-oft OIL,
rollin g
17205 5
172055
11205 5
112251
18 et
..
62 chaagiog to departure
17225 3
172254
Il
17225 5
171255
17225 5
172159
172301
172304
afternoon,
- E
1862,
good eye . .
eh
. .
2000
Il 1862, good afternoon,
chili fligh t
lefel 9 0
111306
172307
El
II
passing
- 1
90, roger
- E
El 11 1862 contact Aasterdae on
112308
171541
124 .8 7
112544
BL2 .
BOL 01319 2
II
11254 5
- A
114 .87 .
- E
By e
- 0
Iesterdae
good da y
172516
111546
111546
17255 1
111556
sing
61 11
1861,
good evening, pas-
4300
11155 3
- 0
112559
ILA
Lao
je
de
die
El
LI,
211
zo
hebben
io
verband
rant die klimt voor geen
ee t
mete r
die 61 I1 ?
[Can you accept
ILA 137 this ray,
ding the
because this El
EI II,
II
regar climb s
like a brick]
11155 9
- A
111600
17I600
- 0
- E
111605
11260 6
El Il
1861, hello, climb to
maar da's geen problee m
[Yo,
bot
that's
Ok dan krijg
112601
17260 1
Yee,
[Okay,
oo problem]
je e l
you'll get
it ]
flight level
21 0
- 0
110, roge r
ILA- 0
Amsterdam,
112601
11261 8
111622
goedenavond,
flight level
]Aasterdan,
good eveziog,
flight level
171613
-[LA
111626
Coeieavood
112621
[LA
231
climbing
231
and eh . .
club to
21 0
evenping
flight level
231 climbin g
90 1
ILI
flight level
[Good
ELI
90
[LA
237 and eh
..
climb to
210]
[LA- 0
Climbing flight level
Speedbird 943,
110,
ILI
131
11161D
11263 4
-811
climb to flight level
28 0
111631
112611
BlY-
Flight level
180, Speedbird 91 3
111640
11264 5
-BAY
171648
17164 9
Speedbird
511,
descend to flight leve l
10 0
811- 0
Deseeod flight level 100,
ILI
Speedbird 51 1
111651
11110 0
-[LA
131, direct to Gereiaghans/e u
171101
11170 2
Ill- 0
Direct Gerniaghausjeo,
City 051, contact
ILA
231,
that you
112104
11171 0
-[LC
112123
1111
111127 11
BLZ . 3
Dhsseldorl
119 .11,
good
da y
[LC
119 .11 good day,
City 057
I
101 01311 1
i
17215 0
-811
943, cliob oor flight level
Speedbird
aio
II
172153
172754
811- 0
110, Speedbird
941
172156
172156
- 0
112159
112800
1862,
eayday, eayday,
re have a n
eaergeoc y
El Al
1862 roger, break, KLM
beading
172804
17280 4
El 11
ILA- 0
Taro
El
277
turn lef t
09 0
left 090,
ILK 11 7
172606
17160 6
111808
11
1812 do you
vink to return to Scbip -
17280 6
- Po
172806
bol?
17280 1
Ja
[Yes ]
Pa - 1
112811
El
II die gaat
., . die
[El
11
it is
11180 9
ltfiraative,
Tura
eayday, eayday,
is
. .eh set
os aan
't
is retarding
desceodidg
een eayday
teru g
zakke n
. .eb rith a
eayday . . .
right oor )
eayda y
111811
11361 1
right
yon eb
1]1811
taste
..
18
heading 260,
is your to
the
field eb
rest eb
..
. .,
behin d
dis -
eiles
17281 2
- To
Chec k
112812
11181 7
111821
11181 3
loger,
ber
3,
re
bave
fire oo eogioe naher nua -
re bare fire on esgide ooeber 3
toger, beading 210 for dororin d
110 dorsrio d
61 II 1862,
111821
111814
112815
17283 1
sddace vial 040 at 11 toots
17283 1
1118) 5
- T
172833
111614
E
-BLS
El
11
(61 II
1866 Coat
terog
eet eel eayda y
1866 is retarsiog rich a uyday]
loge r
173875
17181 5
Lafthansa
5594,
cootie. lasterdal 123 .15
172839
11287 6
- To
17283 6
17183 6
111841
to - I
Ja
17183 6
(Yes ]
172816
lij
heeft een eogioe os
Daar . .
eh
..
[It's got aa
Bing . .
eh
..
tire,
It -
Ip
Ja
(Tes ]
draait s d
dororiod voor de 0 6
eogioe os fire,
it's
oor tar -
dovovidd for the 06)
171837
171177
- I
Tat zeg je nes ?

That do
yon
say?]
17213 1
172139
lp - It
lk vee( sog
eigenlijk,
sief rat ie beeft precie s

die El 1 1
fI don't Ivor yet fiat's exactly the lat ter ritte this El Il]
M.
80E 01319 2
J
17214 0
I DLI- 0
121 .85,
bye bye
112840
11214 1
112840
] At - Ap
112141
-BAY
Speedbird 941,
contact laastricht
127 .62
11214 1
172843
[El Al
1p - It
1862
is returning? )
Ja
[Yes )
112842
11284 2
EI Al 1862 koot terag ?
At - Ip
172144
it ga gelijk de
Ot,
heeft een aaydey call

[Okay,
rill
inspectie
hi j
geplaatst ?
iaaediately
. .. .
the is-
spection, be did lake a uayday-call? )
111141
IIY- 0
127 .62
.. .
112841
11284 4
- To
172845
11284 5
- 0
El
11
1862 lost ouaber
engine,
aoaber
3 and naober
and alder
Ok,
that's copie d
(Okay,
that's copied )
11184 5
engine
Ip - I t
11284 5
11284 5
112849
[Yes )
It - Ip
111846
172846
To - 1
171846
11284 7
- Po
To - 1
112850
ok
..
(Okay
voor 06
. .
for 06
..
. .]
julli e
[It rill be transferred to yaa
112141
11184 8
lij toot no bij
Ja
right nor ]
Ja, is goed
[Yes,
tbet's
. .
. .. .
Ob
clay
eh bij
. .]
beeft :tuber
1 ea
suike r
2 engine verlore n
( . .oh
. . ..
eh
and it
bas lost tuber
ai d
au ger 2 engine )
17185 0
- E
Roger
186E
112150
17285 1
- To
172652
11285 2
To -
- To
- 0
112856
verlo . . .
2)
Ja
Ok
[Okay ]
To - 1
112154
11285 4
eo
(Yes ]
172852
11115 1
(Lost outlier 3 and
11285 2
11285 2
hater
Das geef naar alas denk i k

(So,
think you had better give
ai alert )
Hit rill be tie moray ia Ise for se a t
11215 4
lasterdan?
172856
Ip - It
Inter 2 lad saber 3 elgile doe' 't die t

[laaber 2 and asher
3 eagiaes are
hope -
Mire )
11215 5
112855
- Po
Eh
..
(Eh . .
doen r e
re'll do that)
11185 6
172851
112157
112901
1L2. S
taaray
06 ]a Ise sir,
It - 1p
laser
(Maier
. ..
.. .
06 ?
06? )
surface ried 040 a t
21 hots, QII 1012
102 01319 2
11185 8
lp
At
11285 8
11215 8
112158
11290 1
- 0
1012,
re
regoest 11
Ja
[Yes ]
At -
lp
Ok
(Okay )
for landing
172904
17290 4
- Cc
112905
11290 5
- E
112906
loger,
cao
you
call Approach
oor 121 .2 fo r
11290 5
let
de
Braadree [
[Fire-brigade]
Cc - B
yoor line-op?
Brandyeer,
06 eet
112917
. .
..
tree
eb . .
eb
. .
Joebo
koot
terug va n
uitgevallen colores,
verder bericht el
[Fire-brigade,
. . el
o volg t
volgt no g
Jasba is
retoroing
fro* 06 rith tro engines inoperative,

tollor
. .
11290 1
- 0
111 .2,
- E
ly e
..
rill
eh . .
tollor
yo u
additional intonation e b
later ]
bye by e
11190 8
17290 1
171908
11291 3
11291 4
Ell- 1
--lasterdas
--
- Cc
112914
0 . .
[0
eh
..
. . baan
eh
..
06 ?
rimy
06? ]
Approacl, Shaerock 606
112911
11291 5
Cc -
112915
11291 6
- Cc
-Ell
171921
Stalrock 606 descend

1011,
to 3000
Oki, re koen d'r aa n

[Okay,
Cc - 8
172917
17191 8
06
[lanvay 06 ]
112911
11291 1
Baan
re're on our ray ]
hot a ve l
(Thant you ]
feet on QO B
yon can expect delay doe
to
aa eeer -
geocy coeioq j e
17292 4
Ell- 1
( . . Unreadable . . 1
Schipbol,
El
cy,
re're
112929
11192 5
- 1
el
engine
..
Al
1862,
inoperative
probably :
re bave an
nneber t . . eh . .
I . . badly
eeergen-
11191 5
l and
112926
- A
laar zit ie nu ?
[That's it' s
position nar? ]
readable . . ,
'ioteodioq' or 'retaruinq'1
Ian -
112910
11291 8
111931
- T
lijftje of
[Dolt . .
..
eh
eb . .
11 ui t
. . 12 tiles oat]
172928
At - Aa
Airport 1, Tore n
Aa - It
Toren,
112929
17293 0
112930
[Airport I,
[Toyer,
rover ]
Airport
lirport 1]
101 81311 2
11293 2
- E
172931
El Al
1862, roger
copied about your ewer -
gency, contact 118 .4 tor your
Iine-up
37293 2
Check
17297 2
At -
Aa
172932
Atjnbeer
. .
getregen
een
is,
ei
..
die zojuist gestar t
kort terug, rotor 2 en 3 tij) 'age heeft eer
172942
re hebber
[Sir,
..
El
returning,
uayday-call
..
Il,
re
jast got tie lessag e
that bas
ergines
jast departed,
1 and 3
re, he rade a uyday call,

intoned
- 1
geplaatst ,
Braadleer reeds gevaarscbuv d
de
eh
that aa
17193 9
lI
re hebben tojoist door -
El Al,
is
are iaoperati re alread y
tie Fire-brigade)
118 .4, bye
172940
17294 1
- 0
Ja
- I
leb
112941
17294 1
[Fes)
172941
17294 2
- 0
11294 2
17294 2
je
[lave
'm
you got iti l
Ja
[Fes )
- A
172942
Oki
[Okay]
17294 3
171945
17194 9
Ir
Schiphol, El Al
cy,
172957
1862,
tive,
request
Ap - At
Ja
At - A p
)omentj e
11295 3
( ..
muddle
..
. .
9
..l
unreadable . .I )
[One aunt )
Ip - It
172953
You request 21, in that use heading

360 the headirg, descend
1012,
tied
tie rind
is
Ja
[Fes ]
360 ,
to 2000 feet o r
050
at 22
173002
It - Ap
Schrijf
jij
ik heb
113006
bet op
of moet ook nog
de inspecteur
de Draadteer
things also . . . .
inspector
11300 6
Ap - It
113006
113007
113009
doen
or do bav e
I're already informed
the Fire-brigade
th e
as yell ]
Ok
[Okay ]
It - Ap
173008
11300 8
and
dinge n
gevaarschrrd e i
is geraarscher d
[Till you 'rite this
. .
1'a goiog
[Fes )
11295 3
IL2.
ik ga
[Okay,
27 for lauding
17295 3
113008
016,
re base at emerget -
112952
1r - E
- At
number 3 and suiker 4 engine inopeta -
17295 2
17295 8
Aa
Schrijf jij dat eta
op ?
[hill you trite Ibis dote? )
Ip - It
Ja,
[Fes
ik schrijf bet
rel
op
I'll !rite it don)
101 083/9 2
11300 9
At - A p
17300 9
(Okay )
17300 9
lp - I t
11300 9
It - Ip
113009
- Ir
Roger,
can you say
lr - E
050 at
22
Roger,
chat heading
again
Ooi
[Bye )
113009
11301 0
Ok i
Bedank t
(thanks ]
the viol pleas e
113011
17301 1
173013
11301 4
- Ar
for runny 21 ?
113016
11301 6
lr - E
Beading 360, heading 360 and

a right taro onto cross
first and you've got only 1
eiles to g o
froe present positio n
113015
11702 5
than give you
the localise r
- Ar
loger 36, copied
117021
11303 2
- T
lij
gaat Baar 27 de El
it veet
113031
Bt
II 1162
. . .,
niet precies hoeveel
dos
Bijl
di e
gaat vliegen
[It's going
I
to 27
tie El 11 1162 . . .,
doet ]nov exactly lov tiny tiles
so
it
viii cover ]
113031
- 1
173041
lee check,
vaar zit
scope, pal
vest 1S Bijl ?
ie voor tij
op d e
[lo elect, That's i~ position for se

the
11304 0
It - lp
173040
on
scope, doe-vest IS eiles? )
Kolentj e
[One noieat ]
17304 1
lp - It
113042
Ja,
dat bad
[Teal,
did
je tee,
yon copy,
27 ?
11104 1
- T
27?)
lee,
hij gaat
bijna ; dip s
je
door de Dater tarter
21
starts
je
rechtsos moet
It
eve' el . . . codrdineren
173041
[lo, it's abort to cross the otter utte r

21 ; so
pot
bare to el
.. .
coordinate foo r
departtres to the right )

,
17304 2
It - lp
113043
11304 3
Ja
(Yes )
lp - It
loll
173043
17304 4
It-111B
Airport
iet
Brandveer, lier de Toren, d e
desbetreffende
113050
list gaat Baar Daal 21, i k
lerhaai baas 2 7
[Airport 1 and Fire-brigade,
slis
Tover, the aircraft coucerued vil]

for roovay 27, I
is the
bea d
repeat rtlvay I1)
173D4
1730SO
- I
01,
ik rol
'u
eet de 11 1
[Oh, the 211 is rolling noel
lot
01111 2
1]-
I
111051
limy
hale .]
- I
luny
hi . . .
113051
11705 1
- At
111053
Begrepen ran
[Tover,
Braadteer 1,
Fire-brigade 1
Tore n
understood(
11305 3
111053
11305 4
lr - T
113051
[nail
g ijl
Ik leb die
of
I(taae)
about
El 11
10 te gaan voor
I
bare got
10 eiles
et die leeft tea

21
the El
to go
and
Al
it ba s
for runny 21]
17305 5
It
Begrepen lij k
la -
At
Toren,
113056
11305 7
[Oaderstood,
173056
11705 0
- Ir
073100
Ja check,
ve zetfee bet
veer is geraarscbavd
licht
11310 0
It
- T
113101
[Tover,
Iraod -
the lights ,
beet alerted,
(reeel ]
Ok
[Okay]
11311 6
la
- At
113111
11311 1
Ar
- E
113119
El
Al
to
toocbdoro?
1861 abat is
Airport 1 ]
(Duaal
(Tes check, veil stiktb os

the Fire-brigade las
aas,
lijk ]
Airport
the distance you nee d
11311 1
Airport 1, Tore n
la - It
Is bet de
[Airport 1,
It - la
Tared
freiguter? ]
Inderdaa d
Ia
- It
Ea
heeft ie verder
ve
eogites
- Ar
12 ailes final
ve
teed for
tog iets gezegd, bebal -
Wares sit ?
(lad did he report
LI ?
[Indeed ]
173116
17312 1
vrachtkist vas El
it tie El it
[Is
113111
113123
Airport 1 ]
It - la
113120
11312 0
irport
[Toyer,
113111
11311 9
Tares,
aaytbisg else,
except
okt? ]
larding
113129
11112 6
117116
17313 0
Ir
173134
11314 0
- lr
113141
11314 3
riles Eital
at . .
riles track riles you teed ?
lr - E
Ir
bot troy
. . . Flap one
riles
113145
11314 6
Teal, hor my
Oki,
final
. . re teed . .
10 0
leading
100
liet bekend
Nun]
eb correcti -
eh
. . a
1 1
for lardin g
right right beading
heading
It - la
100,
right
righ t
113141
11315 6
113200
Ar
teelt
ie
) poes
it have any additional troth
eng
zeer ellende
(naaal ?
e
(naaal?]
ILL . 9
BOL 01319 1
11320 0
Ar
113202
11320 3
- Ar
113205
Motor 3
eo 4 heeft ie nie t
(It hasn't got engines
3 lad
Die tijd gerood uit
verder geen
ea
4)
extr a
ellende ?
(They are just out and to extra
trouble oa
top? )
113206
Ir
- T
113201
113201
liet dat it ne t
(lot as far as I Inv )
- Ir
113209
Check,
[floc),
ga je dat nog even

can you elect
informeren?
this, please?)
11310 8
Aa
- It
17320 9
Ir
- T
113209
till
1, hoeveel
Toren, lirport
113109
[Tower, lirport 1,
nit ?
hor tan miles oat? )
Ja
[Yes)
11321 1
It
- la
. ..
rechts, a
da's begrepen
173211
dat hij
[.. .
rijdt
op de I rechts ua ,
lirport
motor Sea
1,
it boor zojuis t
4 nit beeft staa n
1 right, you're nor driving on the 1
right, that's understood lirport 1,

heard
11321 5
Ar
113120
El ll 1861,
ooaber
jast
to be sore,
- Ir
lacher
..
jas t
your engine s
la
- It
l en 4 uit,
113120
113224
3 and 4 are shat off )
l and 4 are oat?
11311 8
11322 0
that engines
land 4 are out
problems vitte
and re have
[3
hoeveel
and 4 out, bow
g ijl lit
is ie ?
many miles out? )
. . eh
oor flaps
11311 3
It - Aa
113125
Moaeetje
[
One touent,
wordt geteld,
.. .
11 vij l
they're coentiog,
.. .
12
Wes )
11322 5
Ir
- E
?robin with the flaps, roger
113211
113226
la - It
111121
11322 1
Ir
- T
Ind Ilapproblea s
- Ar
En Ilapprobleas ?
11322 9
[led flapprobleas?)
113130
12 g ijl,
is begrepen
[12 ailes, that's
.. eh
understood . .
eh
. .]
113228
11322 9
113230
17121 0
Ir - T
la - It
li beo
rrij
van 01 1
[Pt clear of 011 )
Yes
113231
11323 1
173133
It - la
0 bent rrij van

[You're clear of
de 011,
hedaxtt lirport I
the Ill,
thank s
Airport 1 )
11323 1
Ir
lethal 100, El 01 116 2
113231
11313 9
Ir
Thaut you 1862
113240
BhA .
10
801 083/9 2
II
~-
113155
It
- la
., lirport 1, re krijgen
dat ie
113300
ooh oog
zojuist ooh doo r
tlapproDleas Deelt, das
be t
vordt raarschijslijh heel de baa n

[lad
os
lirport
teat
1, ve jast got
it Das
tie isforuati -
tlapproDleas
rill probably seed de
as reil,
total
reovay -
..
. .
so i t
ies9tl
11330 0
lr
113706
Oily,
eadtag
el
uistaioisg
..
. . ei . .
110 . .
and
tarrin g
nn
nn
nn
la
II
Dat
is bosrep: : Toren,
de lasding
(!oren,
tollor
ei
it rij
ea
eves achter de ucbise aa s
fiat's aaderstood,
. .
eb
..
6 ril l
Ibe aircraft after lasdia9 1
11330 S
113301
11330 6
n
11331 0
Ir
Say again
113110
17331 1
Ir
Tost
11331 3
Ir
Oat speed
n
..
ei
160
113311
17331 5
[That's
lirport
understood,
lirport
n
lr - E
1)
-nn
-nn
nn
speed?
is
Dat is begrepen,
.nn
..n n
nn-
11])11
Tht la
113108
nn
nn
173111
113331
Ir
113711
n
11331
nn-n,,.
113331
Ir - E
El 11 1861
173315
Dat Leb ik
'saver gegeret
(8e bas ben
given
east)st e
it at least)
nn
ribt right tars beading 11 0
adjust os the localizer,
nn-
cleared for ap -
proac b
113363
11331 6
nn
Ir
lr
11JJ6S
tight right 310

nn
nn
11335 1
nn
nn
nn
nn
la - T
113351
11335 3
[Toren .
la
lirport I )
lirport
n
la - T
113357
nn__
lirport 1
113351
11335 S
nn
Tore',
(faal), beeft ie eel iniquity ge declared,
of dat niet?
[(fase), did ie declare au esergescy, or

did le sot? )
113351
- la
11360 0
113400
lij Leeft
sayday geroepen
[le called Kaydan)
173358
Ia
- T
nn
Payday geroepen ?
[Called sayday?)
fOL 083/81
11340 1
- la
113401
17341 8
Ar
- E
EI 11
tarn heading 290,
track 'tiles
173427
[Yes ]
1862 you're about to cross the loci -
liter due to your speed,

right
aa
to go,
12
matinee tb e
heading 290,
tract tiles
12
to go
173420
la - B
Brandteer 1 vin Airport 1,
177425
deze intern
het is bi j
alen vliegtui g
[Fire-brigade
trot Airport
1,
trot to s
on it's interval etergency aircraft]
17342 6
- la
Eh . .
173429
intern alai'
van
Brandyeer 1
[eh
..
vliegtuig, begrepe n
internal eaergeocy aircraft, la -
derstood fro' Fire-brigade 1 )
17342 8
- Ar
Roger
19 0
El ll
1862 farther
173429
1734{ 8
Ar - E
113452
17345 2
beading
- Ar
right,
heading 310 ,
31 0
110
173452
17345 4
la - T
173455
11145 5
- Aa
lr - E
173502
El 11
1862 continue descent 1500
Airport
1, Tore n
[Airport 1,
Aa -
177459
17345 8
[Tover, Airport l )
177496
11345 7
Toren, Airport
Bet is
tover [
intern alas vliegtui g
(It's interaal
feet ,
1500
113500
Aa
173504
loten alai' vliegtaig,
bedankt,
den al bet uitgaande verteer

(Internal eaergeocy aircraft,
re're graonding all outbound
11350 3
etergency aircraft[
- Ar
tij
bon -
eas t
thans ,
traffic ]
1500 and ve have a controlling problea
173505
17350 4
113505
17150 6
113508
Ar - E
ion have controlling probleas
as
la - T
p at is begrepe n
[that's understood (
veil ,
roger
17751 1
lr - t
173514
Bij zit dit dik dik in de probletes,

ook tet
z'1
no n
control s
[He's in deep deep deep trouble, nov sith

his controls
17351 5
- Ar
173511
as yell ]
Das ook problesev let
z'n controls,
check
(So problas eitb his controls as veil ,

check )
17351 8
117518
lr - T
Ja
Ili. :
10Z 08319 2
173520
It
Ia
port
Dij,
113524
1, Toren,
d'r kost
steeds
tee r
hij leeft ook problemen set de con -
trot s
(Airport
I, Tover,
le's basing
it's getting corse ,
problems
vit)
the controls a s
yell )
113525
- Ir
TAI11 6T 101 IJ1b4FS, 6T 100 AAPLAPS TA IL,
173511
MID 1711011
going dors,
. . . . Going
dors
1862 ,
going darn copied going dov e
[I1156 Alb T16 /LIPS, ILL T16 PUPS IAIS6,

Will
T16 CHI . . . .
dors,
going
deus
Going dors
1862, goin g
copied going dovo)
171521
la
- It
113521
Dat is begrepen Tore n

[ p over,
that's ooderstood]
17353 8
la - B
173531
113540
11354 5
Ir
173545
17354 1
113541
Ir
- E
Ja
. . . E1
(les
II
. . . El
1862
11
van Airport I
from lirport 1 ]
- la
Braodvee r
[Fire-brigade )
la - I
Lachine oa de landing
volge n
173543
[Folios the aircraft after
't Is gebeur d
17354 5
Ja, da's begrepen van Braodvee r
[It's over]
113546
your heading
1862
1,
[Fire-brigade,
173540
17354 1
Braadveer
11154 1
poor beading)
At - la
113549
Airport 1, ziet
o daar bet
volt
in
- la
[Tes that's n'derstood
landing ]
fro' Fire-brigade ]
't
oosten? Bij
is gecrashed
[Airport 1,
do yon see tie fire is th e
east? It bas crashed ]
17355 0
Ar
113551
17355 2
geen
zin,
(It's so use,
Ar - 1
173552
11355 3
't leeft
feb
- Ir
is gecrashed
(obit)
(nare) )
je 'a gezien ?
[Did
173554
hij
it bas crashed
you see
17355 2
it?)
173553
la -
At
Ja,
da's begrepe n
(Tes,
that's
soderstood )
lis grote rookvolk Doves de sta d

[One big cloud
ot
smoke over
the city]
17355 4
Ia - I
173555
11355 5
It - T
113557
Sjees, set
bij
(Gee,
inside
just
IP
( . . DoreadaDle
. .l
van lirport I
(( . . DoreadaDle . .) from
lirport
1 )
insid e
IT]
17355 6
- la
lirport I
113556
11155 7
la - I
173600
lachioe is i' bet verlengde vao baan 2 7

gecrasbed
(The aircraft has crashed in the exte'de d
centre-line ot
17360 1
Ir
Ir
- T
173601
17360 2
173604
Bij
many 21]
I? ?
(fear T?? )
rest vno V P
173602
[file vest of TT]
173606
mijl
- la
II
. .. .
is
er ook bekend vaar ie precies ligt?
[Eh
ja
is er
. . . . yes
is
..
el . .
there
vas
. . el
. .
de Tore' ,
from
th e
Toyer, do they kast its exact position?]
IOS
01115 2
173607
- 0
173610
vijl vest van IF,
1 mijl vest vest va n
Tees p
(i
mile vest of VP, 1 mile eest vest o f
'Yeesp' ]
11361 1
113613
17361 3
- lr
113615
I mijl
vest vas Yeesp zei
- T
mijl
eest vu Yeesp,
bedaalt
(1 mile vest of 'Yeesp',
thuds )
je (saai) ?
[Did you sap 1 mile vest of
'Ieesp '
(null )
11361 6
L !^ _
113611
Ir
- T
1 mij]
vest
van I?,
[les, i mile vest of
ja
YPJ
Verder geen relevante li t

[lo fattier relevant
l0Z 013/V l
APPENDIX 4 .2
TRANSCRIPT OF TELEPHONE COMMUNICATIO N
BETWEEN ATC AND COAST GUARD
RIJKSLUCHTVAARTDIENS T
Directie Luchtverkeersbeveiligin g
Bureau Operationele Zake n
Schiphol-Centrum
BOZ 92/44 8
R E C O R D ER V ER S L A G
Bandnummer : A- 2
Kanaal
: 23 (inductie telefoonlijn met Kustwacht IJmuiden )
Frequentie :
Betreffende : Kontakt met RCC IJmuide n
Datum
Tijd
(UTC)
: 04-10-1992
Van
Aan
A = Algemene verkeersleiding (ACC )

R = RCC IJmuide n
Begintij d
173137
A
Algemeen verkeer (naam), goedenavon d
(naam), IJmuiden goeienavond .
Daa g
Weet je iets van een vliegtuig met problemen in d e

buurt van Hilversum Naarden ?
Eh . . is bekend bij ons j a
D'r is een motor afgerold of zoiets ?
Ja eh . . ik weet weet niet precies wat er is, maa r

het is eh . .'t is bij ons onderkend en eh . . ze staa n
in kontakt met ons in ieder geva l
Dus die kist die is nog eh . .airborne ?
Ja hij was net airborne, ik dacht dat het 'n eh . .

een El Al wa s
Niet ge-crashed dus of zo ?
Nee nee nee nee ,
Ok
Maar we weten erva n
Goed zo ,
Zeg bedankt, ho i
Eindtij d
A
173204
Hoi .

ElAl Flight 1862

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RAAD VOOR DE LUCHTVAART

AIRCRAFT ACCIDENT REPORT

Hoofddorp, February 24 1994 .

History of the fligh t

The aircraft was on a flight from John F . Kennedy Internationa l

At 17 :28 .57, El Al 1862 was informed that runway 06 was in use an d

date of birth : 21-01-193 3

profession : Airline Transport Pilot employed by El Al sinc e

last medical check : 07-07-1992 .

licence : Israeli ATPL no . 340, first issue 20-09-1960 .

total flying experience : 25,000 hours flying experience . B747 :

The First Office r

date of birth : 07-05-196 0

profession : Airline Transport pilot with El Al sinc e

last medical check : 20-06-1992 .

licence : Israeli ATPL no . 2844, first issue 04-11-1987 .

total flying experience : 4,288 total hours ; flying experienc e

The Flight Enginee r

date of birth : 23-05-193 1

profession : Flight Engineer with El Al since 19-06-195 5

last medical check : 25-08-1992 .

licence : Israeli Flight Engineers license no . 82 .

total flying experience : 26,000 hours ;

- holder left El Al on 22-05-1991 for a period of 3 month s

nationality and registration : Israel, 4X-AX G

aircraft type : Boeing 747 Freighter ; Type : 258 F

engines : 4 Pratt & Whitney JT9D-7 J

The aircraft was registered in the Israeli aircraft registe r

At the time the aircraft departed Amsterdam Airport, th e

All the required inspection and maintenance actions ha d

Pylons, Fuse Pins and Nacelle Attach Fitting s

The pylon, fuse pins and attachment fittings that comprise th e

Pylon to Wing Attachment Desig n

The design of the engine nacelle and pylon incorporate s

Four separate and independent main hydraulic supply systems ar e

The pneumatic system consists of a manifold of ducts and valves tha t

HYD SYS' '

Primary airplane control is provided by ailerons, elevators, an d

The airplane fuel system provides a means of storing fuel in th e

Engine Fire Detection and Extinguishing System s

The engine fire detection system on each engine consists of tw o

Logic of fire warning indication

Service Bulletins and Airworthiness Directive s

Since the certification of the Boeing Model 747 numerous Servic e

Service Bulletins Applicable to Midspar Fuse Pin s

The first Service Bulletin for midspar fuse pins, SB 747-54-2063, wa s

Service Bulletins Applicable to Diagonal Brace Fuse Pin s

Service bulletin 747-54-2066 was issued November 7, 1979, afte r

Service Bulletins Applicable to Attach Fittings

Service Bulletins Applicable to the Nacelle Strut Rear Engin e

Service Bulletins 747-54-2033/2042/2059 and 2065 cover the subject s

Weather information was obtained from the meteorological servic e

A high pressure area centred over the southern part of Scandinavi a

Conditions at the time of the Cras h

Wind and temperature condition s

Aerodrome Terminal Information Service CATIS)

Communications and Recording s

ATC Communication Recording s

Other Communication Recording s