DCA01MA031

NTSB accident investigation · Embraer EMB-120 · West Palm Beach, FL · March 19, 2001

Accident · No injuriesMajor investigationFinal report
Date
March 19, 2001, 18:30 local (23:30 UTC)
Place
West Palm Beach, FL
Injuries
28 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N266CAEmbraer EMB-120
Weather
Dusk
Status
Completed · report December 18, 2002
Report
Approved by Office Director
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20010319039099A
Case key
51941

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the failure of the flight crew to maintain airspeed during an encounter with severe icing conditions, which resulted in an inadvertent stall, loss of control, and structural damage to the airplane.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Altitude deviation,uncontrolledCruise
Airspeed - not maintainedFlightcrewCause
Stall - inadvertent
Aircraft control - not maintainedFlightcrewCause

Analysis

On March 19, 2001, about 1825 eastern standard time, an Empresa Brasileira de Aeronautica, S/A (Embraer) EMB-120, N266CA, operated by Comair Airlines, Inc., as flight 5054, encountered icing conditions while in cruise flight at 17,000 feet mean sea level (msl) and departed controlled flight, descending to an altitude of about 10,000 feet. The pilots recovered control of the airplane and diverted to West Palm Beach, Florida, where they landed without further incident. The 2 flight crewmembers, 1 flight attendant, and 25 passengers were uninjured, and the airplane sustained substantial damage to the elevators and the horizontal stabilizer. Flight 5054 was operating under 14 Code of Federal Regulations Part 121 as a scheduled international passenger flight from Nassau International Airport, Bahamas, to Orlando International Airport, Florida.

The flight departed in visual meteorological conditions (VMC). In postaccident interviews, the captain stated that while in VMC, the airplane flew normally. Flight data recorder (FDR) data indicate that about 7 minutes before the upset occurred, the airplane was at about 17,000 feet msl, with the autopilot engaged and airspeed stabilized near 200 knots indicated airspeed (KIAS). These data indicate that beginning about 1818, the airspeed slowed to 185 KIAS over a 1?minute period as the autopilot began trimming airplane nose-up (ANU) to maintain altitude. The airspeed then decreased to about 137 KIAS over the next 3 minutes. The airplane continued to maintain a constant altitude as the autopilot trimmed the airplane from about 0 to about 7 degrees ANU. The first officer stated that immediately before the upset occurred, he switched the leading-edge deicing system inflation cycles switch from "light" to "heavy" and the propeller deicing system cycles switch from "norm" to "cold" because he saw "more ice accumulation than he had ever seen" on the wing and spinner. FDR data indicate that when torque indications for both engines were about 55 percent and the airspeed was about 141 KIAS, the autopilot was disengaged. The airplane then pitched down and rolled about 80 degrees to the left, then rolled back to near level. During the next 20 seconds, engine torque increased to about 98 percent on both engines, the airplane rolled about 110 degrees to the left, returned to level flight, rolled about 130 degrees to the right, returned to level flight, then rolled 360 degrees to the right before returning to near wings level, with torque on both engines stabilized at about 22 percent. The airplane's behavior during the upset is consistent with an ice-induced stall event. The first officer stated in postaccident interviews that the stick shaker and aural stall warning, which is part of the airplane's stall warning/protection system, activated but did not indicate whether it was before, during, or after the upset. The Safety Board's investigation could not precisely determine whether or when the stick shaker and aural stall warning activated.

Meteorological data at the time of the accident indicate that Comair flight 5054 may have encountered an area of icing conducive to the formation of super-cooled large droplets (SLD). The EMB-120 is not certified for flight in SLD conditions. FDR data indicate that airspeed had decreased to only about 137 KIAS before control of the airplane became difficult and altitude was no longer maintained. However, according to the Embraer EMB-120 Airplane Flight Manual (AFM) performance section, the airplane stalling speed is about 115 knots calibrated airspeed for an airplane at the accident airplane's approximate gross weight at the time of the event (23,800 pounds).

Factual narrative

History of flight

On March 19, 2001, about 1825 eastern standard time, an Empresa Brasileira de Aeronautica, S/A (Embraer) EMB-120, N266CA, operated by Comair Airlines, Inc., as flight 5054, encountered icing conditions while in cruise flight at 17,000 feet mean sea level (msl) and departed controlled flight, descending to an altitude of about 10,000 feet. The pilots recovered control of the airplane and diverted to West Palm Beach, Florida, where they landed without further incident. The 2 flight crewmembers, 1 flight attendant, and 25 passengers were uninjured, and the airplane sustained substantial damage to the elevators and the horizontal stabilizer. Flight 5054 was operating under 14 Code of Federal Regulations Part 121 as a scheduled international passenger flight from Nassau International Airport, Bahamas, to Orlando International Airport, Florida.

Comair flight 5054 departed Nassau about 1741 in visual meteorological conditions (VMC). In postaccident interviews, the captain stated that before the upset, the airplane flew normally. Flight data recorder (FDR) data indicate that about 7 minutes before the upset occurred, the airplane was at about 17,000 feet msl, with the autopilot engaged and airspeed stabilized near 200 knots indicated airspeed (KIAS). According to both pilots, shortly after cruise flight was established at 17,000 feet (about 1822), the airplane entered a cloud and that, shortly thereafter, the windshield frosted over with pebble-like rime ice. The captain stated that he then instructed the first officer to activate the anti-icing and deicing systems and that once these systems were activated, ice on the windshield started to melt within a couple of seconds. The captain stated that the ice detection light illuminated and, about 1 minute later, went out. He also stated that he looked outside and saw remnants of light ice between the ribs on the wing deicing boots but that there was no buildup of ice on the post where the windshield wiper arm attaches to the fuselage.

FDR data indicate that beginning about 1818, the airspeed slowed to 185 KIAS over a 1-minute period as the autopilot began trimming airplane nose-up (ANU) to maintain altitude. The altitude and speed remained constant for the next 3 minutes. According to FDR data, beginning about 1822, the airspeed decreased to about 183 KIAS then decreased to 137 KIAS over the next 3 minutes. The airplane continued to maintain a constant altitude as the autopilot trimmed the airplane from about 0 to about 7 degrees ANU. The first officer stated that immediately before the upset occurred, he switched the leading-edge deicing system inflation cycles switch from "light" to "heavy" and the propeller deicing system cycles switch from "norm" to "cold" because he saw "more ice accumulation than he had ever seen" on the wing and spinner.

FDR data indicate that about 1825, when torque indications for both engines were about 55 percent and the airspeed was about 141 KIAS, the autopilot was disengaged. The airplane then pitched down and rolled about 80 degrees to the left, then rolled back to near level. During the next 20 seconds, engine torque increased to about 98 percent on both engines, the airplane rolled about 110 degrees to the left, returned to level flight, rolled about 130 degrees to the right, returned to level flight, then rolled 360 degrees to the right before returning to near wings level, with torque on both engines stabilized at about 22 percent. The maximum nose-down pitch attitude was 60 degrees; the maximum recorded airspeed was about 240 KIAS, and the maximum vertical acceleration during recovery was about +3.6 G.

FDR data indicate that airspeed had decreased to about 137 KIAS before control of the airplane became difficult and altitude was no longer maintained. According to the Embraer EMB-120 Airplane Flight Manual performance section, the airplane stalling speed is about 115 knots calibrated airspeed for an airplane at the accident airplane's approximate gross weight at the time of the event (23,800 pounds.) The airplane's behavior during the upset is consistent with an ice-induced stall event. The first officer stated in postaccident interviews that the stick shaker and aural stall warning, which is part of the airplane's stall warning/protection system, activated but did not indicate whether it was before, during, or after the upset. The Safety Board's investigation could not precisely determine whether or when the stick shaker and aural stall warning activated.

Interviews with the flight crew indicated that during the event, both of the electronic attitude display indicators (EADI) in the cockpit blacked out and that red flags appeared on the screens. The EADIs displays reappeared after the aircraft came out of the clouds and recovered from the event.

Personnel information

Both flight crewmembers were properly certificated in accordance with Federal Aviation Administration (FAA) regulations. The captain, who was also the pilot flying at the time of the accident, had about 16,000 hours total flight time, including about 9,000 hours in the EMB-120. The first officer had about 1,350 hours total flight time with about 250 hours in the EMB-120.

Aircraft information

The EMB-120 anti-icing system includes electrically heated windshields, angle of attack and sideslip sensors, pitot/static and outflow valve static ports, and the total air temperature sensor. The deicing system includes inflatable rubber boots installed over appropriate regions of the wing and tail leading-edge surfaces and over the engine air inlet lips and engine air bypass ducts. The propeller deicing system consists of electrical heaters directly bonded onto the blade leading edge over a length of 20 inches.

When the inflation cycles switch is selected to "heavy," each ejector flow control valve is energized for 6 seconds and automatically cycles every minute. When the inflation cycles switch is selected to "light," each ejector flow control valve is energized for 6 seconds and automatically cycles every 3 minutes.

The EMB-120 propeller blade leading edge incorporates imbedded electrical resistances for ice protection. The system incorporates two dual-cycle electronic timers that provide selectable cycles; the "cold" cycle is 20 seconds on and 60 seconds off, and the "norm" cycle is 10 seconds on and 60 seconds off.

The EMB-120 stall warning/protection system consists of a three-stage process: first, the control column vibrates (also known as the stick shaker function), second, an aural warning sounds, and, finally, the control column is pushed forward (also known as the stick pusher function).

Meteorological information

Comair flight 5054 was in VMC until about 1818 when it entered an overcast cloud layer with cloud tops around 23,000 feet. Radar data showed that, between 1820 and 1822, flight 5054 penetrated the core of a level 3 convective cell with tops to about 33,000 feet. The temperature at flight 5054's flight altitude was about -3 degrees Celsius. The airplane exited the cell core around 1822 but remained in instrument meteorological conditions through the upset sequence.

Flight 5054 encountered severe mixed icing as the airplane exited the north side of the cell. The Miami Weather Surveillance Radar-1988, Doppler indicated that a strong convective cell was present beneath flight 5054 about the time that the airplane was experiencing icing. Meteorological data at the time of the accident indicate that Comair flight 5054 may have encountered an area of icing conducive to the formation of super-cooled large droplets (SLD). The EMB-120 is not certified for flight in SLD conditions.

Wreckage and impact information

Initial examination of the airplane at Palm Beach International Airport showed no evidence of hail damage to the leading edges of either wing or the horizontal stabilizer. The damage to the right horizontal stabilizer

Aircraft

Registration
N266CA
Reported as
Embraer EMB-120
Category
Airplane
Serial number
120.258
Airframe hours
22,154.8
Engine
Pratt & Whitney PWII8B, 1,800 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 121
Operator
Comair Inc
Airworthiness certificate
Standard, Transport
Departed
NAS · Nassau
Destination
MCO · Orlando, FL

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
None
Certificates
Airline transport, Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Flight hours
16,000 total · 8,000 in this make and model · 9,000 as pilot in command · 166 in the last 90 days · 68 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
26
Injuries
None
Certificates
Commercial, Private, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Flight hours
1,350 total · 263 in this make and model · 1,000 as pilot in command · 116 in the last 90 days · 79 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Dusk
Wind
100° at 8 knots
Lowest ceiling
8,000 ft broken
Temperature
72 °F, dew point 70 °F
Altimeter
29.90 inHg

Docket · 48

The files NTSB released with the investigation on August 14, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 24.7 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 129 KBOperations 2 - Attachment 1 - Interview SummariesItem 2 · .PDF · 182 KBOperations 2 - Attachment 2 - Summary of EMB-120 SimulatorItem 3 · .PDF · 13 KBOperations 2 - Attachment 3 - Flight 5054 Flight Departure PapersItem 4 · .PDF · 872 KBOperations 2 - Attachment 4 - Comair Winter Operating BulletinItem 5 · .PDF · 110 KBOperations 2 - Attachment 5 - Airplane Flight Manual Propeller Heat UsageItem 6 · .PDF · 103 KBOperations 2 - Attachment 6 - Flight Standards Manual - Cruise Airspeed During Icing Conditions-Item 7 · .PDF · 83 KBOperations 2 - Attachment 7 - Airplane Flight Manual - Flight in Icing ConditionsItem 8 · .PDF · 116 KBOperations 2 - Attachment 8 - Embraer Letter to ComairItem 9 · .PDF · 90 KBATC 3 - Factual Report of Group ChairmanItem 10 · .PDF · 68 KBATC 3 - Attachment 1 - Transcript of radio communicationsItem 11 · .PDF · 210 KBATC 3 - Attachment 2 - Daily Record of Facility Operation - Miami CenterItem 12 · .PDF · 66 KBATC 3 - Attachment 3 - Daily Record of Facility Operation Palm Beach ApproachItem 13 · .PDF · 75 KBATC 3 - Attachment 4 - Personnel Statements - Miami CenterItem 14 · .PDF · 343 KBATC 3 - Attachment 5 - Weather Data - Miami CenterItem 15 · .PDF · 246 KBATC 3 - Attachment 6 - Flight Strips - Miami CenterItem 16 · .PDF · 55 KBMeteorology 5 - Factual Report of Group ChairmanItem 17 · .PDF · 989 KBMeteorology 5 - Attachment 1 - NWS Surface Analysis and 500 Milliabr Analysis ChartsItem 18 · .PDF · 486 KBMeteorology 5 - Attachment 2 - Surface Weather Observations for MYNN, MYGF, and KPBIItem 19 · .PDF · 329 KBMeteorology 5 - Attachment 3 - KMIA Upper Air DataItem 20 · .PDF · 350 KBMeteorology 5 - Attachment 4 - KAMX Archive Level III Base Reflectivity and VAD Widn Profile ProductsItem 21 · .PDF · 1.4 MBMeteorology 5 - Attachment 5 - GOES-8 Visible and Infrared ImagesItem 22 · .PDF · 2.1 MBMeteorology 5 - Attachment 6 - Pilot ReportsItem 23 · .PDF · 144 KBMeteorology 5 - Attachment 7 - Aviation Area Forecasts for the Southeast AreaItem 24 · .PDF · 407 KBMeteorology 5 - Attachment 8 - Terminal Aerodrome Forecasts for KMCO and KPBIItem 25 · .PDF · 871 KBMeteorology 5 - Attachment 9 - Winds and Temperatures Aloft Forecasts for the Southeast AreaItem 26 · .PDF · 90 KBMeteorology 5 - Attachment 10 - Convective SIGMETs for the Eastern United States and McIDAS PlotsItem 27 · .PDF · 1.1 MBMeteorology 5 - Attachment 11 - AIRMETs for the Southeast Area and McIDAS PlotItem 28 · .PDF · 354 KBMeteorology 5 - Addendum 12 - Non-convective SIGMETItem 29 · .PDF · 54 KBMeteorology 5 - Attachment 13 - High Level Significant Weather Prognosis ChartsItem 30 · .PDF · 251 KBMeteorology 5 - Attachment 14 - Center Weather Service Unit ProductsItem 31 · .PDF · 351 KBMeteorology 5 - Attachment 15 - Bahamas Meteorological Office ForecastsItem 32 · .PDF · 72 KBMeteorology 5 - Attachment 16 - EMB120 and B190 Flight Path PlotsItem 33 · .PDF · 76 KBMeteorology 5 - Attachment 17 - Automated Aircraft Weather ReportsItem 34 · .PDF · 499 KBMeteorology 5 - Attachment 18 - Astronomical DataItem 35 · .PDF · 85 KBMeteorology 5 - Addendum 1Item 36 · .PDF · 405 KBSurvival Factors 6 - Factual Report of Group ChairmanItem 37 · .PDF · 91 KBSurvival Factors 6 - Attachment 1 - Flight Attendant TrainingItem 38 · .PDF · 75 KBSurvival Factors 6 - Attachment 2 - Flight Attendant InterviewItem 39 · .PDF · 746 KBSurvival Factors 6 - Attachment 3 - Passenger InterviewsItem 40 · .PDF · 1.3 MBSurvival Factors 6 - Attachment 4 - Request to Federal Bureau of Investigation to Reformat PAL-DV video tapeItem 41 · .PDF · 85 KBAirworthiness Factual Report of Group ChairmanItem 42 · .PDF · 10 photos · 6.3 MBAirworthiness - Addendum 1 - Navigation SystemItem 43 · .PDF · 76 KBFlight Data Recorder 10 - Factual Report of Group ChairmanItem 44 · .PDF · 18 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 45 · .PDF · 69 KBFlight Data Recorder 10 - Attachment 1 - Graphical PlotsItem 46 · .PDF · 399 KBFlight Data Recorder 10 - Attachment 2 - Tabular DataItem 47 · .PDF · 124 KBAircraft Performance 13 - Group Chairman's Aircraft Performance StudyItem 48 · .PDF · 2.2 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.