# NTSB ATL99LA067: de Havilland DHC-6-200, N838MA, Lantana, FL, April 5, 1999 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: April 5, 1999, 09:45 local (13:45 UTC) - Place: Lantana, FL - Coordinates: 26.580093, -80.06958 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.5801&lon=-80.0696&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 6 minor, 4 uninjured - Status: Completed, report April 25, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 46023 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL99LA067 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/46023/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=46023 - Page: https://openairdocs.org/ntsb/ATL99LA067 ## Probable cause The pilot's failure to secure the engine oil filler cap during the preflight inspection that resulted the subsequent loss of engine power, and his in-flight decision to attempt a single engine go-around with full wing flaps extended. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - lubricating system,oil filler cap - not secured (cause) - aircraft preflight - inadequate, pilot in command (cause) - lubricating system - starvation (cause) - 1 engine - Forced landing, descent - emergency - In flight collision with terrain/water, go-around (vfr) - object - other - flaps - improper use of, pilot in command (cause) - in-flight planning/decision - improper, pilot in command (cause) ## Analysis The pilot reported that prior to takeoff, he completed a preflight inspection of the airplane that included checking the engine oil quantity. The line personnel topped off the oil reservoirs, and reportedly secured the engine oil reservoir filler caps. Approximately two minutes into the flight, the right engine oil pressure warning light illuminated. The pilot informed Palm Beach Approach Control of the engine oil pressure problem, shut down the right engine, and returned to Lantana. As the flight approached runway 03, the pilot heard a radio transmission from another airplane taxiing for takeoff. As the pilot continued the approach, with full flaps extended, he elected to go-around 1500 feet from the approach end of the 3000-foot runway. The airplane collided with the ground during the go-around maneuver to runway 15. The wreckage examination also disclosed that the right cowling showed oil streaming back from behind the engine and onto the wing strut. Inspection of the oil filler cap revealed that it had not been properly installed. ## Factual narrative On April 5,1999, at 0945 eastern daylight time, a DeHavilland DHC-6-200, N838MA, collided with the ground during a single-engine go-around to runway 15 at the Palm Beach County Airport in Lantana, Florida. The non-scheduled air taxi flight was operated by Carib-Air Cargo Inc., under the provisions of Title 14 CFR Part 135 with a visual flight rules flight plan filed. Visual weather conditions prevailed at the time of the accident. The commercial pilot and four passengers were not injured, and five passengers received minor injuries. The airplane sustained substantial damage. The flight departed Lantana, Florida, at 0942. The pilot reported that prior to takeoff, he completed a preflight inspection of the airplane that included checking the engine oil quantity. After the oil levels were checked it was determined that additional engine oil was needed. The line personnel topped off the oil reservoirs, and reportedly secured the engine oil reservoir filler caps. The pilot also stated that he rechecked the oil cap after the oil was added and no one else touched the oil caps before the flight departed. According to the pilot, approximately two minutes into the flight, the right engine oil pressure warning light illuminated. The pilot informed Palm Beach Approach Control of the engine oil pressure problem. The pilot shut down the right engine, feathered the right propeller and returned to Lantana. As the flight approached runway 03, the pilot heard a radio transmission from another airplane taxiing for takeoff. As the pilot continued the approach, with full flaps extended, he elected to go-around 1500 feet from the approach end of the 3000-foot runway. The airplane collided with the ground during the go-around maneuver to runway 15. The pilot said he never saw the other airplane on runway 03 during his initial approach. An examination of the crash site revealed that the airplane was in a nose low attitude. The airplane was orientated 180 degrees from the departure heading. The examination of the airplane also disclosed that the left wing assembly separated from the rear attach point. The airplane examination revealed that the right propeller was in the feather position. Also the nose was destroyed, the nose wheel separated from the airplane. The wreckage examination also disclosed that the right cowling showed oil streaming back from behind the engine and onto the wing strut. Inspection of the oil filler cap revealed that it had not been properly installed. ## Aircraft - Registration: [N838MA](https://openairdocs.org/deregistered/N838MA-2000-03-21), registration cancelled 2000-03-21, S/N 188 (OpenAirDocs) - Reported make and model: de Havilland DHC-6-200 - Registry model: [Dehavilland DHC-6 TWIN OTTER](https://openairdocs.org/model/dehavilland-dhc-6-twin-otter) (registry code 2802606) (OpenAirDocs) - Category: Airplane - Serial number: 188 - Airframe hours: 16659 - Engines: P&W PT-6-20 550 horsepower turbo prop - Damage: Substantial damage - Flight: Part 135 - Operator: Carib-Air Cargo Inc., - Registered owner: Cca Financial Services - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, April 2, 1999, 10 hours before - Departed: LNA - Destination: ISM, KISSIMMEE, FL - Airport: LNA, Palm Beach Airpark, runway 3, 3,010 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 8,000 total, 200 in this make and model, 8,000 as pilot in command, 250 in the last 90 days, 90 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: 2,000 ft broken - Temperature: 75 °F, dew point 64 °F - Altimeter: 30.00 inHg - Observed at: PBI, 13 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19990405003079A](https://openairdocs.org/incident/19990405003079A), Apr 5, 1999: Dhav DHC6, West Palm Beach, FL, Substantial damage. Isua air taxi acft experienced #2 engine problems after take-off and returned to land on rwy 3, while N838MA was on short final another acft pulled onto the… ## Docket (2 files) The files NTSB released with the investigation on July 5, 1999, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=46023. 500 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 431 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419167&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement S (item 2, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40107235&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.