RAAD VOOR DE LUCHTVAARTNederlands AviationSafety BoardAIRCRAFT ACCIDENT REPORT92-1 1EL AL FLIGHT 1862BOEING 747-258F 4X-AXGBIJLMERMEER, AMSTERDAMOCTOBER 4, 1992FINAL RAPPORTon the accident with EI Al 1862on October 4, 199 2at Amsterdam - Bijlmermeer1. 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 to 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 . Müller, mr . H.P. Corssmit, mr . J . Smit, mr . C. Barendregtand 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 . V CONTEN SSYNOPSI S 1 FACTUAL INFORMATION 1 .1History of the Flight 1 .2Injuries to Person s 1 .3 Damage to Aircraft 1 .4 Other Damag e 1 .5Personnel Information 1 .6Aircraft Informatio n 1 .6 .1 Genera l 1 .6.2Pylons, Fuse Pins and Nacelle Attach Fitting s 1 .6.3Aircraft Design 1 .6.3 .1Pylon to Wing Attachment Desig n 1 .6 .3 .2Hydraulic System s 1 .6 .3 .3Pneumatic Syste m 1 .6 .3 .4 Electrical System 1 .6.3.5 Flight Controls 1 .6.3.6 Fuel System 1 .6.3.7Engine Fire Detection and Extinguishing Syste m 1 .6.4Service Bulletins and Airworthiness Directive s 1 .6.4 .1Service Bulletins Applicable to Midspar Fuse Pins 1 .6.4.2Service Bulletins Applicable to Diagonal Brace Fuse Pin s 1 .6.4.3Service 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 .1General Condition s 1 .7.2Conditions at the time of the Cras h 1 .7.3Aerodrome Traffic Information Service (ATIS ) 1 .8 Aids to Navigation 1 .9Communications and Recording s 1 .9 .1ATC 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 Area 1 .12.3 Damage to Aircraft 1 .12.3.1 Damage to Right Wing Structure 1 .12.3.2 Damage to Engine s 1 .12.3.3 Damage to Hydraulic Systems 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 Systems 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 .16Tests and Researc h 1 .16.1 Metallurgic Investigation of Outboard Midspar Fuse Pi n 1 .16.2 Metallurgic Investigation of Inboard Midspar Fitting Lug 3 1 .16.3 Bird Impact 1 .16 .4 Sabotag e 1 .16.5 Trajectory Engine No . 3 1 .17 Additional Informatio n 1 .17.1 Other Related Incidents and Accident s 1 .17.2 Additional Investigation 2 ANALYSI S 2.1 Genera l 2.2 Engine Pylon Separatio n 2.3 Design and Certification Assessment 2.4 Final Loss of Contro l 2.4.1 Controllability 2.4 .2 Performance 2.4.3 Synthesis 2.5. Performance of the Flight Crew 2 .6 ATC Performance 2 .7 Actions Taken Since the Acciden t 3 CONCLUSIONS 3.1 Finding s 3.2 Probable Cause s 4 RECOMMENDATIONS 5 APPENDIXE S 1 PHOTOGRAPH 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 COMMUNIC。