Aviation Accident Summaries

Aviation Accident Summary CHI03FA099

St Louis, MO, USA

Aircraft #1

N179GA

Dassault Aviation DA-20C

Analysis

The twin engine turbofan powered airplane was ditched into a river after a complete loss of power from both engines. The airplane was on a second approach to land on runway 30R after having been instructed by air traffic control (ATC) to climb during the final approach segment of the first approach due to inadequate separation from another airplane. Subsequent to the first approach, the airplane was issued vectors for the second approach by ATC. Communications transcripts show that the flight crew asked ATC how far they would be vectored during the second approach, but the flight crew did not inform ATC of their low fuel state until the airplane was already on a "base turn...to join final." The airplane subsequently lost power from both engines. During interviews, both pilots stated that there were no problems with the airplane. The second-in-command (SIC) stated that the airplane "ran out of fuel" and that the fuel quantity indicators read 0 and 100 pounds when each respective engine stopped producing power. The SIC also stated that after being instructed to climb to 5,000 feet after their first approach, he questioned the pilot-in-command about landing at another airport located about 14 nautical miles west-southwest of the destination airport. The SIC said that the PIC elected to continue with the second approach to the original destination. Research indicated that the flight crew did not obtain a weather briefing prior to the accident flight. Additionally, the Terminal Aerodrome Forecast that was valid at the time the aircraft's flight plan was filed showed a forecast ceiling consisting of overcast clouds at 1,500 feet above ground level at the aircraft's arrival time at the destination. 14 CFR Part 91.169 requires that an alternate airport be listed in the flight plan when forecast ceilings are less than 2,000 feet. No alternate was listed in the flight plan for the accident flight. Additionally, 14 CFR Part 91.167 requires that aircraft operated in instrument meteorological conditions maintain fuel reserves that allow flight to the intended destination and then continued flight to the listed alternate, and an additional 45 minutes at normal cruise speed. In 1993, the FAA/industry advisory committee developed advisory material for fuel planning and management for 14 CFR Part 121 and 135 air carrier flight operations, but the material was never published.

Factual Information

HISTORY OF FLIGHT On April 8, 2003, at 1850 central daylight time (CDT), a Dassault DA-20C, Fan Jet Falcon, N179GA, operated by Grand Aire Express, Inc. as flight GAX179, was destroyed when it was ditched into the Mississippi River near St. Louis, Missouri. The airplane was approaching to land on runway 30R (9,003 feet by 150 feet), at the Lambert-St. Louis International Airport (STL), when it lost power to both engines. The 14 CFR Part 135 non-scheduled domestic cargo flight was operating on an instrument flight rules flight plan in instrument meteorological conditions at the time of the accident. The pilot and first officer received serious injuries. The airplane departed from the Del Rio International Airport, Del Rio, Texas, about 1630. The airplane received vectors from air traffic control (ATC) for the instrument landing system (ILS) 30R approach to STL. During the first approach, the STL tower controller initially cleared the airplane to land on runway 30R. Later, the airplane was instructed to climb to 3,000 feet and to contact departure control. The airplane was then vectored for a second approach to runway 30R. While being vectored for the second approach, the flight crew asked controllers several times how far they were to be vectored away from the airport. When the airplane was on a base leg for landing, the flight crew reported that they had a "fuel limitation." They were then immediately issued vectors and cleared for the ILS 30R approach. After being switched to the tower frequency, the flight crew declared an emergency. The crew reported to the tower controller that they lost power to both engines. The airplane was subsequently ditched into the Mississippi River. In an interview after the accident, the pilot-in-command (PIC) stated that during the first approach to land, when they were inside the outer marker of the approach, ATC instructed them to climb to 5,000 feet and "fly the heading." He stated that they were then vectored for another approach. The PIC stated that during the second approach they asked ATC how far out they were going to be taken and ATC responded 20 miles. He said that they were again cleared for the approach, intercepted, and broke out of the overcast. He stated that they went about 1 1/2 miles after that when the engines failed. He stated that during the second approach they questioned ATC several times as to how far away from the airport they were going to be taken on the approach. The PIC stated that they informed ATC of their fuel situation. He stated that they also asked ATC why they had been instructed to go-around on the first approach and that ATC did not give them an answer. The PIC stated that he had been assigned to the airplane since April 5, 2003, and that there were no problems with the airplane. In a later telephone interview, the pilot stated that the airplane had departed DRT with 6,200 pounds of fuel on board. The pilot subsequently provided a load manifest that indicated that the airplane was limited to 25,000 pounds takeoff weight due to runway and climb limitations. The manifest showed that the actual takeoff weight was 24,646 pounds. In an interview after the accident, the second-in-command (SIC) stated that they had received vectors for the ILS 30R approach and that everything went "fine" until they were less than 7 miles from the airport. At that point, ATC instructed them to climb to 5,000 feet. He said that they were then vectored for another approach, during which time, they were sent 23 miles west of the airport, and then 17 miles east of the airport prior to being vectored back to the final approach for runway 30R. He stated that their fuel was critical and that the right engine stopped producing power about 15 miles from the airport. He said that the left engine stopped producing power about 30 seconds after the right engine stopped producing power. When questioned as to why he thought the engines stopped producing power, he said that they "ran out of fuel." He stated that when the right engine failed the fuel quantity indicator read zero, and when the left engine failed the fuel quantity indicator read 100 pounds. When asked if there were any problems with the airplane the SIC responded "No, the airplane was good." He also stated that after being instructed to climb to 5,000 feet after their first approach, he questioned the PIC about landing at the Spirit of St. Louis airport. The SIC said that the PIC elected to continue with the second approach to STL. The Spirit of St. Louis Airport is located about 14 nautical miles west-southwest of STL. According to personnel statements made by FAA Air Traffic Control Specialists, the accident airplane was given missed approach instructions during its first instrument approach when adequate separation from another arriving aircraft could not be maintained. PERSONNEL INFORMATION The PIC held an airline transport pilot (ATP) certificate issued by the Federal Aviation Administration (FAA) on April 13, 2001. The ATP certificate listed ratings for multi-engine and single-engine airplanes. Single engine operations were limited to commercial privileges. He also held a certified flight instructor certificate with single-engine airplane, multi-engine airplane, and instrument airplane ratings. His first class medical certificate issued October 21, 2002 listed no limitations. According to the operators records, the PIC had accumulated 3,221 total flight hours including 1,270 in the same make and model airplane as the accident airplane. Operator records show that the PIC was hired on April 11, 2000, and that he had satisfactorily completed upgrade training for the DA-20 on April 13, 2001. Training records indicate that the PIC's most recent Airman Competency/Proficiency Check, as required by 14 CFR Part 135.293, was satisfactorily completed on October 24, 2002. The SIC held an ATP certificate issued by the FAA on April 24, 2001. The ATP certificate listed ratings for multi-engine and single-engine airplanes. His first class medical certificate issued October 21, 2002 listed the limitation that the pilot wear corrective lenses. According to the operators records, the SIC had accumulated 5,758 total flight hours including 1,532 in the same make and model airplane as the accident airplane. Operator records show that the SIC was hired on October 26, 1999, and that he had satisfactorily completed upgrade training for the DA-20 on April 24, 2001. Training records indicate that the SIC's most recent Airman Competency/Proficiency Check, as required by 14 CFR Part 135.293, was satisfactorily completed on May 8, 2002. AIRCRAFT INFORMATION The airplane was Dassault DA-20, Serial number 100. The airplane was a two-engine turbofan powered low-wing airplane with an aluminum primary structure. Each engine was mounted in a pod attached to the fuselage side near the rear of the airplane. The accident airplane had been configured for cargo operations. According to maintenance records, the airplane had accumulated 15,899.3 hours total time in service as of the date of the accident. The airplane was part of an Approved Aircraft Inspection Program and was last inspected on March 17, 2003 at 15,866.1 total hours. Two General Electric CF700-2D2 engines rated at 4,500 pounds of thrust each powered the airplane. The left engine, serial number 222J077, had accumulated 4,136.8 hours total time in service, 2,020.4 hours since overhaul, and 600.9 hours since inspection as of the date of the accident. The right engine, serial number 304-571, had accumulated 7,798.9 hours total time in service, 7,798.9 hours since overhaul, and 806.1 hours since inspection as of the date of the accident. The airplane fuel system consisted of a wing and center wing fuel tank and a rear fuselage compartment tank per side. Fuel is transferred from the respective wing fuel tanks to the corresponding rear fuselage tank, and then to the respective engine. A crossfeed system is also provided. A magnetic ground fuel gauging system is contained in each inboard wing fuel tank for ground check of fuel quantity. Each wing and center wing tank combination has an electronic fuel gauging system consisting of 4 capacitance type sending units which are connected to a two-pointer gauge in the pilot compartment. One of the gauge pointers indicates the mass-quantity of fuel contained in the left wing/center wing fuel tank combination. Likewise, the other pointer indicates the mass-quantity of fuel contained in the right wing/center wing fuel tank combination. The rear fuselage mounted fuel tanks each contain a float type electronic fuel quantity sending unit. These sending units are connected to a two-pointer gauge to indicate the mass-quantity of fuel in the respective rear fuel tank. Right and left side low pressure transfer failure warning systems are installed to indicate the end of fuel transfer, transfer pump stoppage, or transfer pump failure. Each wing/center wing tank has a capacity of 571.3 gallons or 3,817.2 pounds of fuel, and each rear fuselage mounted tank can hold 108.5 gallons or 732.2 pounds of fuel. METEOROLOGICAL INFORMATION The recorded weather for STL at 1853 was: Wind- 020 degrees at 8 knots; Visibility- 2 statute miles; Weather condition- light rain and mist; Ceilings- 500 feet broken, 1200 feet overcast; Temperature- 4 degrees Celsius; Dewpoint- 4 degrees Celsius; Altimeter setting- 30.25 inches of mercury; Remarks- Surface visibility 2 1/2 statute miles, ceiling variable from 500 to 1000 feet, sea-level pressure 1024.7 millibars. The Terminal Aerodrome Forecasts (TAF), for STL encompassing the accident time were obtained. At the time that the accident airplane's flight plan was filed, the TAF was: Station Identifier: KSTL Date and time of origin: April 8, 2003 at 1220 CDT Valid period: Valid from 1300 CDT on April 8, 2003 until 1300 CDT on April 9, 2003 Forecast wind: 350 degrees at 11 knots Forecast visibility: Greater than 6 statute miles Forecast sky condition: Overcast clouds at 1,500 feet above ground level The TAF listed that the forecast after 1000 CDT on April 9, 2003, the day after the accident, would be: Forecast wind: 350 degrees at 11 knots Forecast visibility: Greater then 6 statute miles Forecast sky condition: Broken clouds at 3,500 feet above ground level COMMUNICATIONS On April 8, 2003, at 0918, a Direct User Access Terminal System (DUATS) abbreviated weather briefing request for GAX179 was received and processed by DynCorp Information Services LLC. At 1420, a flight plan was filed for GAX179 using DUATS. The listed route of flight was from Gainesville, Florida, to Del Rio, Texas. On April 8, 2003, at 1324, an individual contacted the San Angelo Automated Flight Service Station and filed an IFR flight plan from Del Rio, Texas, to St. Louis International for GAX179. The caller requested flight level 330 and a direct route of flight. The pilot listed for the flight plan was the accident pilot. No alternate destination was listed. The caller requested no further services after the flight plan was filed. No record of a weather briefing for the flight from DRT to STL was found. Transcripts for radio communications between STL air traffic controllers were obtained. At 1817:10, N179GA checked in on frequency with STL approach control. Between 1817:10 and 1832:24, STL approach vectored and subsequently cleared N179GA for the ILS runway 30R approach to STL before handing communication with the airplane off to STL tower controllers. At 1832:56, N179GA checked in on frequency with STL tower. Between 1832:56 and 1836:16, the airplane remained on the STL tower frequency. During this time, the STL tower controllers initially cleared N179GA to land and then subsequently instructed N179GA to climb to 3,000 feet and continue on the localizer. The airplane was subsequently handed off to STL departure control. At 1836:38, N179GA checked in on frequency with STL departure control. The transcripts contain no mention of a low fuel situation prior to 1836:38. The following excerpts are from transmissions between GAX179 and various control positions for the time period from 1836:38 to 1851:21. The abbreviations for the various entities making transmissions are as follows: Transmitting entity Abbreviation N179GA N179GA STL Approach Control Arrival South Position STL-AS STL Approach Control Departure South Position STL-DS STL Tower Local Control North Position STL-NL STL Tower Local Control Local Three Position STL-L3 1836:38 N179GA uh departure grand aire one seventy nine three thousand (unintelligible) maintaining heading 1836:43 STL-DS grand express one seventy nine saint louis departure radar contact climb and maintain five thousand 1836:49 N179GA uh maam five thousand you know what's uh what's up with uh why we are got a missed approach on that one seventy nine 1836:56 STL-DS grand express one seventy nine maintain five thousand i didn't understand your last sir 1837:01 N179GA uh we're climbing five thousand and i've a question that we were missed on that three zero right approach you know how far we're gonna go out this way 1837:09 STL-DS grand express one seventy nine turn left heading one eight zero 1837:13 N179GA one eight zero one seventy nine 1837:39 STL-DS grand express one seventy nine it be best to ask the tower once you get on the ground we don't know what happened 1837:46 N179GA okay and how long uh before we go on landing sir 1837:49 STL-DS about a twenty mile final 1838:24 STL-DS grand express one seventy nine turn left heading one two zero 1838:27 N179GA one two zero on heading one seventy nine 1839:04 STL-DS grand express one seventy nine maintain one niner zero knots for spacing 1839:07 N179GA one niner zero for spacing one seventy nine 1840:06 STL-DS grand express one seventy nine traffic one oclock two miles same direction a boeing seven five seven descending out of six thousand six hundred for six thousand 1840:15 N179GA one seventy nine uh we have in check 1840:26 STL-DS grand express one seventy nine contact saint louis approach one two six point five five 1840:30 N179GA twenty six fifty five 1840:42 N179GA good afternoon grand aire one seventy nine four thousand one two zero heading 1840:52 STL-AS grand aire one seventy nine saint louis roger maintain five thousand 1840:55 N179GA maintain five thousand uh one seventy nine 1843:16 N179GA departure grand expre grand aire one seventy nine how far are we going to stay on this heading sir 1843:22 STL-AS it'll be about ten more miles sir will that be all right 1843:25 N179GA uh we 1843:28 N179GA sir is it possible can we turn ah a little bit earlier than ten miles one seven nine 1843:33 STL-AS okay i'll turn you in sooner 1843:35 N179GA thank you 1844:15 STL-AS grand aire one seven nine reduce speed to one seven zero 1844:19 N179GA one seven zero one seventy one seven nine 1844:41 STL-AS grand aire one seven nine turn left heading zero three zero 1844:44 N179GA zero three zero one seven nine 1845:31 N179GA saint louis tower uh approach grand aire one seventy nine 1845:40 STL-AS grand aire one seventy nine say again 1845:42 N179GA yes sir how far are we gonna go on the zero two zero we might have uh little bit uh fuel uh limitation here 1845:49 STL-AS you're on a base turn sir to join final 1845:51 N179GA okay roger that one seventy nine 1846:17 STL-AS grand aire one seventy nine i may have to take you about a half a mile across final 1846:22 N179GA sir we have to make landing here we have uh limited fuel here 1846:27 STL-AS grand aire one seventy nine turn left a heading three three zero intercept three zero right localizer 1846:32 N179GA three three zero intercept the localizer one eight one seventy nine 1846:50 STL-AS grand aire one seventy nine six miles from exale cross exale at three thousand five hundred cleared i l s runway three zero right approach maintain one seven zero knots til five mile final 1846:57 N179GA roger si

Probable Cause and Findings

The pilot in command's improper in-flight decision not to divert to an alternate destination resulting in the exhaustion of the airplane's fuel supply, and his failure to relay his low fuel state to air traffic control in a timely manner.

 

Source: NTSB Aviation Accident Database

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