Aviation Accident Summaries

Aviation Accident Summary MIA02FA041

Sunny Isles Bch, FL, USA

Aircraft #1

N582HG

Convair Div. of Gen. Dynamics 340-580STC

Analysis

The airline completed weight and balance and dispatch release forms for the initial flight showed an incorrect fuel load at the time the engines were started. The first officer performed a walk-around before the first flight leg which included checking the fuel tanks. A total of 460 gallons of fuel were added to the fuel tanks, and a delay loading cargo occurred. After both engines were started to begin the first flight, the engines remained operated for between 9-10 minutes before they were secured due to a radio problem. Maintenance personnel reracked the VHF radios, and again the engines were started where the airplane remained on the ramp 3-4 minutes before taxiing to the runway. The airplane remained at the runway hold short area for between 20 and 25 minutes before returning to the ramp due to a radio problem. The engines were secured, and a new VHF radio was purchased and installed. The company did not prepare new dispatch release, or weight and balance forms for the flight taking into account the additional fuel consumed with the engines operating. The engines were started, and the airplane was taxied to the runway and departed for the planned first leg. The airplane landed uneventfully at the destination airport where the cargo was offloaded. The first officer performed a walk-around which included checking the fuel tanks; 300 gallons of fuel were added to the fuel tanks (150 gallons in each side). The flight departed to return and when near the coastline, the flight was vectored to an airport other than the planned destination due to a issue with U.S. Customs. The flight landed uneventfully, and experienced a delay clearing customs. While on the ground before departure on the accident flight, the first officer reportedly performed a walk-around which included checking the fuel tanks with the captain looking on. The first officer reported that each fuel tank had approximately 1,100 pounds of fuel, and he and the captain both agreed before takeoff as to the quantity of fuel on-board as indicated by the magna-sticks. No fuel was purchased. Following starting of both engines for the accident flight, the first officer checked the fuel quantity gauges indications against the magna-sticks indications he observed; the fuel quantity gauges indicated approximately 200 pounds more. The flight departed, proceeded eastbound, and climbed to approximately 2,100 feet msl. During a right turn from a southeast to westerly heading, the right engine experienced a loss of horsepower which decreased from 900 to zero. The right engine was secured as a precaution, and priority handling to the destination airport was requested with air traffic control. The left engine horsepower remained the same (900) for a period of 31 seconds following the right engine horsepower decrease, then increased to 2,200, and remained at that value for 1 minute 13 seconds. The left engine horsepower then began to decrease and dropped to zero. The airplane was turned to the east, then turned to the south and ditched. The captain and first officer evacuated but remained with the airplane, and made it to shore where the first officer advised his wife that something was wrong with the fuel gauges. Following recovery of the airplane, pressure testing of the left fuel tank revealed no evidence of preimpact leakage. Pressure testing of the right fuel tank revealed slight leakage past the fuel cap. Boroscope examination of the engines, and functional test of each engine ignition system, fuel control units and fuel pumps revealed no evidence of preimpact failure or malfunction. Examination of the installed magna-sticks revealed no evidence of preimpact failure. The left fuel tank was drained and found to contain 2 gallons of Jet A fuel, while the right fuel tank was drained and found to contain approximately 540 gallons of salt water and 1/2 gallon of Jet A fuel. Fuel consumption calculations performed by FAA personnel revealed that at the time of engine start for the accident flight, the fuel tanks contained approximately 714 pounds of fuel. According to a representative of the engine manufacturer, the amount of fuel drained from the engine components post accident was consistent with, "low residual fuel."

Factual Information

HISTORY OF FLIGHT On December 6, 2001, about 2258 eastern standard time, a Convair 340-580STC, N582HG, registered to World Aviation Services, Inc., and operated by Trans Air Link Corporation, was ditched in the Atlantic Ocean, near Sunny Isles Beach, Florida, following a precautionary shutdown of the right engine and a subsequent loss of engine power from the left engine. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 positioning flight from the Fort Lauderdale-Hollywood International Airport (KFLL), to the Opa-Locka Airport, Opa-Locka, Florida. The airplane was substantially damaged and the airline transport-rated captain and first officer sustained minor injuries. The flight originated about 2250, from Fort Lauderdale, Florida. The captain reported that prior to departing Fort Lauderdale, he went to the airplane after clearing customs from the previous flight from the Bahamas. The first officer performed a quick walk-around which included checking the fuel while he watched. The total fuel capacity was estimated to be between approximately 320 to 340 gallons (2,144 to 2,278 pounds of fuel). The left fuel gauge indicated approximately 200 pounds less than the magna-stick reading while the right fuel gauge agreed with the magna-stick indication. The engines were started, air traffic control was advised the destination was the Opa-Locka Airport, and the flight taxied to the runway. After takeoff the flight proceeded on a heading of 100-110 degrees, climbed to 2,000 feet mean sea level, and while over water, the flight was vectored heading 270 degrees. When the flight was within about 1/2 mile from the shoreline, the captain heard a strange noise he associated with negative torque sense "NTS'ing" from the right engine; there were no lights or indications. A precautionary shutdown of the right engine was performed, and at that point, the left fuel gauge indicated 600-700 pounds of fuel remaining and the right fuel gauge indicated approximately 900 pounds of fuel remaining. The crossfeed valve was opened to provide fuel to the left engine, and air traffic control was contacted and priority handling to the Opa-Locka Airport was requested. He intended on flying to the Opa-Locka Airport on one engine. Air traffic control asked if they were declaring an emergency, and the response was no, he considered the securing of the right engine as a precaution. While the first officer was talking with air traffic control, the same "NTS'ing" occurred to the left engine, which didn't completely lose power. The first officer advised air traffic control that they were going to ditch the airplane. They were unable to see a nearby airport but felt they were close to the Opa-Locka Airport; at that time he didn't know exactly where they were located. He banked to the left and flew towards the ocean, and the left engine lost power completely. The first officer advised air traffic control of the intention of ditching, and he maneuvered the airplane between two buildings, and turned to the south. He wanted to do a restart of the right engine, but didn't think he could because the propeller was feathered, and AC power was needed to unfeather the propeller. The first officer continued talking with air traffic control, and because of safety concerns, a restart of the left engine was not attempted. While flying in a southerly heading at approximately 150 knots, at a low altitude, he asked for full flaps several times. He saw a pier with lights, veered to the left, flared, and heard the tail hit the water. The first officer stated that during his check of the fuel tanks before takeoff, each fuel tank contained approximately 1,100 pounds of fuel. While in the cockpit with the captain before electrical power was applied, he and the captain agreed on the quantity of fuel on-board as indicated by the "drip sticks." After the engines were started for the flight, the fuel gauges were indicating approximately 200 pounds more than the quantity indicated by the "drip sticks." No fuel was added while on the ground at the KFLL airport. Visual flight rules (VFR) flight following was requested with air traffic control (ATC), and the airplane was taxied to and departed from runway 9L. After takeoff the flight was cleared to climb to 2,000 feet on a heading of 100 degrees, and proceeded over the ocean for approximately 1 minute when the flight was vectored heading 270 degrees. At a point in the flight when the shoreline was in sight, he began hearing a "weird sound coming from the right engine." He checked the rpm and fuel gauges, and noted that the right rpm gauge needle was climbing but never to the green arc; the needle was fluctuating. He was prepared to execute the propeller overspeed checklist but noted that the right fuel gauge needle was "making heavy oscillations", and was moving "strong." It moved twice to zero then returned to the original reading. The left fuel tank gauge needle did not fluctuate. He advised the captain he was losing the right engine and with concurrence from him, performed a precautionary shutdown of the right engine using the emergency handle. Power was applied to the left engine, and rudder trim was applied. The captain also began "transferring" fuel from the right fuel tank to the left engine after the right engine was secured. Air traffic control (ATC) was notified of the situation, and priority handling to the Opa-Locka Airport was requested. He thought about restarting the right engine but did not attempt to due to the circumstances. A short time after securing the right engine, the left engine tachometer began fluctuating as the right had, but to a lesser extent. He advised the captain to fly to the ocean and advised ATC of the intent to ditch. The flight was descending at 1,500 fpm and he intended on lowering full flaps but his attention was diverted outside and he could not confirm that the flaps fully extended. The flight proceeded in a southerly direction paralleling the shoreline, and before ditching east of a buoy, he placed his hand on the flight controls. The ditching was soft and he donned his personnel floatation device (PFD); he smelled fuel in the water. A witness observed the airplane flying southeast bound towards the ocean and when near the shoreline, the airplane banked to the right flying southbound paralleling the beach. The airplane was ditched east of a buoy and remained floating after the ditching. Following the ditching, the captain and first officer evacuated the airplane from the first officer's sliding window, waited with the airplane while it moved closer to shore, then made it to the beach with the first officer assisting the captain and assistance from a buoy offered by rescue personnel. While on-shore, the first officer advised his wife in spanish of the ditching, and there was something wrong with the fuel gauges. He advised her he thought they had fuel but didn't, and that he didn't know what occurred because he had fuel and the fuel gauges indicated he had fuel, but then there was no fuel, and everything shutoff. Both occupants were then taken by ambulance to a local hospital for treatment. Review of recorded radar data from the Miami Air Traffic Control Tower revealed that the first recorded transponder return occurred at 2250:30, at which time the airplane was at 200 feet mean sea level (msl) flying on a easterly heading. The flight continued, climbed to 2,100 feet msl which occurred at 2253:10, while flying a east-southeasterly heading. The next radar return 28 seconds later indicates the airplane was at 2,000 feet msl, on a westerly heading. The airplane maintained the westerly heading and approximately 2,000 feet msl until 2256:34, at which time the airplane was on a east-southeast heading flying at 1,000 feet msl. The airplane remained at that altitude and heading for the next radar target 5 seconds later, at which time the airplane began descending and turning towards a southerly heading. The airplane continued descending while flying on a southerly heading until the last recorded radar return at 2257:48, at which time the airplane was at 200 feet msl flying on a nearly due south heading. PERSONNEL INFORMATION The captain was the holder of an airline transport pilot certificate, with a Convair 340/440 type rating, reissued on September 6, 2001. He was the holder of a first class medical certificate which was issued on August 8, 2001, with the limitation, "Holder shall wear lenses that correct for distant vision." He was hired by Trans Air Link in August 2001, and prior to employment had previously flown the Convair 340-580STC airplane. He reported a total flight time of 12,765 hours, with 1,940 hours total time in the accident make and model airplane. He was also reported to have accumulated 1,881 hours as pilot-in-command in the accident make and model airplane. The first officer was the holder of an airline transport pilot certificate, which was issued on December 12, 2000. He was the holder of a first-class medical certificate which was issued on October 15, 2001, with no limitations. He was hired by Trans Air Link in February 2001, and prior to his employment with that company, had not flown the Convair 340-580STC airplane. He reported a total flight time of 2,569 hours, of which 271 hours were in the accident make and model airplane. AIRCRAFT INFORMATION The airplane was initially manufactured as a Convair 340, serial number 46, and was modified in accordance with Supplemental Type Certificate SA4-1100, which included installation of Allison 501-D13D engines. The airplane was equipped with Aero Products propellers model A6441FN-606A. The airplane was also modified in accordance with a Supplemental Type Certificate for installation of Magna-stick fuel level quantity indicators in each fuel tank. METEOROLOGICAL INFORMATION A METAR weather observation taken at the Fort Lauderdale/Hollywood International Airport (KFLL), on the day of the accident at 2253, indicates that few clouds existed at 2,900 feet mean sea level (msl), scattered clouds existed at 6,500 feet msl, the wind was from 110 degrees at 9 knots, the visibility was 10 statute miles, the temperature and dew point were 24 and 22 degrees Celsius respectively, and the altimeter setting was 30.04 inHg. The airplane came to rest 164 degrees and 8.51 nautical miles from KFLL. COMMUNICATIONS The flightcrew was in contact last with Miami Air Traffic Control tower. WRECKAGE AND IMPACT INFORMATION The airplane was first observed by NTSB approximately 2-3 hours after the ditching resting on and parallel to the shoreline with the nose of the airplane heading northbound. The left wing was over the beach, and the right wing was partially submerged in the surf when first viewed by NTSB, and again the following morning. The empennage was separated near the cargo door but remained in close proximity to the fuselage. The right propeller was feathered and the left propeller blades were damaged. Fire department personnel reported smelling a slight odor of fuel initially but the odor quickly dissipated. The airplane was located at 25 degrees 56.03 minutes north Latitude and 080 degrees 07.20 minutes west Longitude. The airplane was recovered to the beach where approximately 2 gallons of Jet A fuel were drained from the left fuel tank. The right outboard magna-stick was checked which indicated approximately 540 gallons of fluid. The right fuel tank was drained and found to contain approximately 540 gallons of water and approximately 1/2 gallon of Jet A fuel. The cross feed fuel line was cut approximately 45 inches outboard of the right side of the fuselage, and also between the left side of the fuselage and the left engine nacelle; no fuel was located when either of the lines were cut. Approximately 2 ounces of fuel were drained from each of the left and right wings main tank drain valves, and approximately 32 ounces of fuel were drained from the right fuel/oil heat exchanger. Approximately 19 ounces of fuel were drained from the left fuel/oil heat exchanger. Only residual fuel was noted at the outlet of the left boost pump, and no fuel was noted at the outlet of the right boost pump. The left and right fuel quantity gauges in the cockpit were found to indicate slight greater than 100 pounds, and slightly less than 800 pounds, respectively. The landing gears were retracted. The airplane was transported to a facility where it was secured for further examination. The left and right fuel tanks were pressure checked; leakage was noted from the left fuel tank on the outboard section of the engine nacelle where damage occurred during recovery. Additionally, leakage was noted from the drain line from the auxiliary fuel pump where impact damage was noted. No leakage was noted from the fuel cap. Pressure testing of the right fuel tank revealed slight leakage from the fuel cap. The magna-sticks from both fuel tanks were retained for further investigation. Boroscope examination of both engines by a representative of the engine manufacturer with NTSB oversight revealed no evidence of preimpact mechanical failure or malfunction. Testing of each engine ignition system from each relay to each igniter revealed no evidence of failure or malfunction. The fuel control unit and mechanical fuel pump from each engine were retained for bench testing which revealed no evidence of preimpact failure or malfunction of either fuel control unit or of either mechanical fuel pump. According to the engine manufacturer's representative, the quantity of fuel recovered from the engine components following recovery of the airplane was consistent with, "low residual fuel." TESTS AND RESEARCH Review of the airplane maintenance records revealed that the left fuel quantity gauge was last overhauled on April 28, 1995, and installed in the accident airplane on September 30, 1996. The right fuel quantity gauge was last overhauled on September 6, 1995 and installed in the accident airplane on April 1, 1996. A discrepancy dated January 27, 2001, indicates, "No.2 fuel quantity indicator reads one thousand pounds lower than number 1." Another discrepancy dated March 20, 2001, indicates, "Fuel quantity gauges need calibrated with 4,000 pounds in both sides R/H 3,500 lbs L/H 2,700 lbs." The corrective action for both discrepancies indicates both fuel quantity gauges were calibrated in accordance with the maintenance manual. There were no further recorded discrepancies related to the fuel quantity gauges. The airplane was last inspected the day before the accident in accordance with a "B" check. Following that check, the Director of Maintenance for Trans Air Link personally checked the quantity of fuel in the fuel tanks using the magna-sticks. He reported that when he checked the fuel tanks, the left and right held 150 and 130 gallons of fuel, respectively. The airplane remained parked until the following morning, when it was positioned to the Florida Air Cargo ramp and 460 gallons of fuel were added to the fuel tanks. The airplane contained 740 gallons of fuel at the time of engine start, for the first flight. The airline completed weight and balance form and dispatch release for the first flight leg indicated there were 4,667 pounds of fuel on-board for the flight. As previously mentioned, the airplane was determined to have a total of 740 gallons of fuel (4,958 pounds of fuel) at the time the engines were started to begin the first flight leg. The flightcrew was scheduled to fly 2 legs on the accident date, the first flight leg was scheduled to depart at 0800. A discrepancy with the cargo delayed the first departure. Following starting of both engines for the first flight leg, the airplane remained on the ramp approximately 9-10 minutes with the engines operating. The engines were secured due to a discrepancy with one of the airplane's very high frequency (VHF) radios. A mechanic from Trans Air Link "re-[racked]" the radios, and verified communication capability with ground and local control. The engines were restarted and the airplane remained on the ramp approximately 3-4 minutes before taxiing to the runway. The

Probable Cause and Findings

The inadequate dispatch of the airplane by company personnel prior to the first leg of the flight due to failure of company personnel to prepare a new flight release and weight and balance after considerable time on the ground with the engines operating. Also causal, was the inadequate preflight of the airplane by the captain by which he failed to note the low level of fuel in the fuel tanks before departure resulting in total loss of engine power of both engines due to fuel exhaustion and subsequent ditching of the airplane. A finding in the accident was the inaccurate fuel quantity gauges.

 

Source: NTSB Aviation Accident Database

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