Page:CAB Accident Report, Pan Am Flight 115.pdf/9

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As a result of this accident the company took the following corrective action:

Issued a directive that one pilot give continuous attention to the attitude and flight of the aircraft during autopilot operation.
Reemphasized in pilot training the narrow speed margins between Mach 0.82 and M_ne and the brief interval of time it takes the aircraft to accelerate into critical speed ranges.

Probable Cause

The Board determines that the probable cause of this accident was the inattention of the copilot to the progress of the flight, during the absence of the captain from the cockpit, following the involuntary disengagement of the autopilot. Contributing factors were the autopilot disengage warning light in the dim position and the Mach trim switch in the "off" position.

BY THE CIVIL AERONAUTICS BOARD:

/s/ JAMES R. DURFEE
Chairman

/s/ HARMR D. DENNY
Member

/s/ G. JOSEPH MINETTI
Member

Gurney, Vice Chairman, did not take part in the adoption of this report.