DCA04MA068

NTSB accident investigation · Convair Div. of Gen. Dynamics CV-340 (580) · Florence, KY · August 13, 2004

Accident · FatalClass 1 · MajorFinal report
Date
August 13, 2004, 00:49 local (05:49 UTC)
Place
Florence, KY
Injuries
1 fatal, 1 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N586PConvair Div. of Gen. Dynamics CV-340 (580)
Weather
Visual (VMC)
Status
Completed · report August 9, 2006
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
Air Tahoma, AAI-100, Washington, DC, Kelowna Flightcraft LTD., Transportation Safety Board of Canada, Rolls-Royce Corporation
Safety recommendations
Yes
FAA report
20040813035189A
Case key
59897

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

fuel starvation resulting from the captain's decision not to follow approved fuel crossfeed procedures. Contributing to the accident were the captain's inadequate preflight planning, his subsequent distraction during the flight, and his lateinitiation of the in-range checklist. Further contributing to the accident was the flight crew's failure to monitor the fuel gauges and to recognize that the airplane's changing handling characteristics were caused by a fuel imbalance.

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.

Loss of engine power(total) - nonmechanicalApproach
Fluid,fuel - starvationCause
Checklist - not followedPilot in commandCause
InattentivePilot in commandFactor
Preflight planning/preparation - inadequatePilot in commandFactor
Checklist - delayedPilot in commandFactor
Engine instruments,fuel quantity gage - starvationFactor
In-flight planning/decision - inadequateFlightcrewFactor
InattentiveFlightcrewFactor
Aircraft handling - not recognizedFlightcrewFactor
Forced landingDescent - emergency
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - ground

Analysis

The Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm, AAR-06/03, PB2006-910403.

On August 13, 2004, about 0049 eastern daylight time, Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a cargo flight for DHL Express from Memphis International Airport, Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

Factual narrative

The Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm, AAR-06/03, PB2006-910403.

On August 13, 2004, about 0049 eastern daylight time,1 Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a cargo flight for DHL Express2 from Memphis International Airport (MEM), Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

The flight crew was scheduled to fly the accident airplane on a roundtrip sequence from MEM to CVG.3 Flight 185 departed MEM about 2329. The first officer was the flying pilot, and the captain performed the nonflying pilot duties. During postaccident interviews, the captain stated that the takeoff and climb portions of the flight were normal.

According to the cockpit voice recorder (CVR) transcript, at 0017:49, the captain stated that he was just going to "balance out the fuel here."4 The first officer acknowledged. From 0026:30 to 0027:08, the CVR recorded the captain discussing the airplane's weight and balance with the first officer. Specifically, the captain stated, "couldn't figure out why on the landing I was out and I was okay on the takeoff." The captain added, "the momentum is one six six seven and I…put one zero six seven and I couldn't work it." He then stated, "so…we were okay all along."

At 0030:40, the first officer stated, "weird." At 0032:31, the captain stated, "okay just let me finish this [the weight and balance paperwork] off and…I'm happy," and, about 2 minutes later, he stated, "okay, back with you here." At 0037:08, the captain contacted Cincinnati Terminal Radar Approach Control (TRACON) and reported an altitude of 11,000 feet mean sea level.6 About 1 minute later, the first officer stated, "something's messed up with this thing," and, at 0039:07, he asked "why is this thing?" At 0041:21, the first officer stated that the control wheel felt "funny." He added, "feels like I need a lot of force. it is pushing to the right for some reason. I don't know why…I don't know what's going on." The first officer then repeated twice that it felt like he needed "a lot of force." The CVR did not record the captain responding to any of these comments.

At 0043:53, when the airplane was at an altitude of about 4,000 feet, the captain reported to Cincinnati TRACON that he had the runway in sight. The approach controller cleared flight 185 for a visual approach to runway 36R and added, "keep your speed up." The captain acknowledged the clearance and the instruction. The first officer then stated, "what in the world is going on with this plane? sucker is acting so funny." The captain replied, "we'll do a full control check on the ground." At 0044:43, the approach controller again told the captain to "keep your speed up" and instructed him to contact the CVG Air Traffic Control Tower (ATCT).

At 0045:11, the captain contacted the CVG ATCT and requested clearance to land on runway 36R, and the local control west controller issued the landing clearance. Flight data recorder (FDR) data indicated that, shortly afterward, the airplane passed through about 3,200 feet, and its airspeed began to decrease from about 240 knots indicated airspeed. At 0045:37, when the airplane was at an altitude of about 3,000 feet, the captain started the in-range checklist,8 stating, "bypass is down. hydraulic pressure. quantity checks. AC [alternating current] pump is on. green light. fuel panel. boost pumps on."

About 0046, the first officer stated, "I'm telling you, what is wrong with this plane? it is really funny. I got something all messed up here." The captain replied, "yeah." The first officer then asked, "can you feel it? it's like swinging back and forth." The captain replied, "we've got an imbalance on this…crossfeed I left open." The first officer responded, "oh, is that what it is?" A few seconds later, the first officer stated, "we're gonna flame out." The captain responded, "I got the crossfeed open. just keep power on."

At 0046:45, the CVR recorded a sound similar to decreasing engine rpm. Immediately thereafter, the first officer stated, "we're losing power." At 0046:52, the first officer stated, "we've lost both of them. did we?" The captain responded, "nope." FDR data showed that, about 1 second later, a momentary electrical power interruption occurred when the airplane was at an altitude of about 2,400 feet. At 0046:55, the CVR stopped recording. Airplane performance calculations indicated that, shortly after the power interruption, the airplane's descent rate was about 900 feet per minute (fpm).

According to air traffic control (ATC) transcripts, at 0047:12, the captain reported to the CVG ATCT that the airplane was "having engine problems." The local control west controller asked, "you're having engine problems?" The captain replied, "affirmative." At 0047:28, the controller asked the captain if he needed emergency equipment, and the captain replied, "negative.'" This was the last transmission received by ATC from the accident flight crew. The FDR continued recording until about 0049. The wreckage was located about 1.2 miles short of runway 36R.

Findings

1. The captain and first officer were properly certificated and qualified under Federal regulations.

2. No evidence indicated that flight crew fatigue was a factor in this accident, and no evidence indicated any preexisting medical or behavioral conditions that might have affected the accident flight.

3. The airplane was properly maintained in accordance with Federal regulations and approved company procedures.

4. The recovered components showed no evidence of any preexisting powerplant, system, or structural failures. No evidence indicated that any of the airplane's cargo shifted during the flight.

5. Neither the weather nor the inoperative distance measuring equipment on the Cincinnati/Northern Kentucky International Airport very high frequency omnidirectional range was a factor in this accident.

6. Sufficient fuel was on board the airplane for the flight from Memphis International Airport to Cincinnati/Northern Kentucky International Airport.

7. The captain's preflight weight and balance calculations indicated that the airplane was not within takeoff limits; therefore, he should not have allowed the airplane to take off. However, the captain's calculations were incorrect, and the airplane's weight and balance were within limits.

8. The captain did not recognize the importance of the cues provided by the first officer, and he failed to perform expected pilot-in-command duties.

9. The captain was preoccupied with the weight and balance calculations during critical portions of the flight and, as a result, he did not monitor the fuel crossfeed operations, which resulted in a fuel imbalance and unusual airplane handling characteristics.

10. The flight crew did not monitor the fuel quantity gauges or respond properly to the airplane's changing handling characteristics, and the captain did not start the in-range checklist at the appropriate altitude; as a result, the crew missed several opportunities to identify the ongoing fuel crossfeed operations and determine that the airplane's fuel was imbalanced.

11. Although fuel transfer is prohibited on the Convair 580 airplane, fuel transfer can occur during fuel crossfeed operations if the fuel tank shutoff valve for the tank not being used is left open.

12. All of the fuel from the airplane's left tank that was not used by the engines transferred into the right tank because the captain intentionally kept th

Aircraft

Registration
N586P
Reported as
Convair Div. of Gen. Dynamics CV-340 (580)
Category
Airplane
Serial number
68
Airframe hours
67,948.9
Engines
Rolls-Royce 501-D13, 3,750 horsepower, turbo propRolls-Royce 501-D13, 3,750 horsepower, turbo prop
Damage
Destroyed
Flight
Part 121
Operator
Air Tahoma Inc
Registered owner
N580, Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 1, 2004
Departed
MEM · Memphis, TN
Destination
CVG · Florence, KY
Flight plan
IFR
Airport
CVG · Cincinnati/Northern Kentucky I, runway 36R, 10,000 × 150 ft, concrete

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
49
Injuries
Serious
Certificates
Private, Airline transport, Flight engineer, Foreign
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 1, 2004
Seat
Left
Toxicology
Performed
Flight hours
2,500 total · 1,337 in this make and model · 32 in the last 90 days · 28 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
36
Injuries
Fatal
Certificates
Flight engineer, Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 1, 2004
Seat
Right
Toxicology
Performed
Flight hours
924 total · 145 in this make and model · 145 in the last 90 days · 69 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC)
Wind
0 knots
Visibility
10 statute miles
Lowest ceiling
7,500 ft overcast
Temperature
55 °F, dew point 52 °F
Altimeter
30.02 inHg

Docket · 52

The files NTSB released with the investigation on January 23, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 35.3 MB in all.

Operations 2-factual report of group chairmanItem 1 · PDF · 19 pages · 568 KBOperations 2-errata 1 to operations factual reportItem 2 · PDF · 1 page · 66 KBOperations 2-attachment 1-interview summariesItem 3 · PDF · 38 pages · 438 KBOperations 2-attachment 2-weight and balance control forms found at accident siteItem 4 · PDF · 3 pages · 158 KBOperations 2-attachment 3--weight list-or-load plan-left in memphis by captainItem 5 · PDF · 2 pages · 248 KBOperations 2-attachment 4-excerpt from air tahoma weight and balance manual explaining use of weight and balance forItem 6 · PDF · 16 pages · 1.0 MBOperations 2-attachment 5-excerpt from air tahoma differences manualItem 7 · PDF · 2 pages · 1.4 MBOperations 2-attachment 6-exerpt from air tahoma runway analysis manualItem 8 · PDF · 2 pages · 1.8 MBOperations 2-attachment 7-pictures of convair 580 fuel gaugesItem 9 · PDF · 5 pages · 3.0 MBOperations 2-attachment 8-nolinor aviation inc fuel crossfeed proceduresItem 10 · PDF · 2 pages · 24 KBOperations 2-attachment 9-ERA airline visual indicator card of fuel crossfeeding in progressItem 11 · PDF · 2 pages · 819 KBOperations 2-attachment 10-logbook page of accident airplane for day prior to accidentItem 12 · PDF · 2 pages · 156 KBOperations 2-attachment 11-copy of fueling record for accident airplaneItem 13 · PDF · 2 pages · 117 KBOperations 2-attachment 12-copy of flight release for accident flightItem 14 · PDF · 2 pages · 181 KBOperations 2-attachment 13-pages from FAA approved aircraft flight manual for the convair 580Item 15 · PDF · 3 pages · 293 KBOperations 2-attachment 14-nolinor aviation's fuel crossfeeding proceduresItem 16 · PDF · 3 pages · 383 KBOperations 2-addendum 1Item 17 · PDF · 4 pages · 152 KBOperations 2-errata to addendum 1Item 18 · PDF · 1 page · 77 KBOperations 2-addendum 2Item 19 · PDF · 1 page · 75 KBOperations 2-addendum 3Item 20 · PDF · 2 pages · 84 KBOperations 2-addendum 4Item 21 · PDF · 2 pages · 111 KBOperations 2-addendum 5 crew injury informationItem 22 · PDF · 2 pages · 10 KBOperations 2-addendum 6 two additional interviewsItem 23 · PDF · 9 pages · 27 KBATC 3-factual report of group chairmanItem 24 · PDF · 9 pages · 248 KBATC 3-attachment 2 FAA accident packageItem 25 · PDF · 53 pages · 4.2 MBATC 3-attachment 3 hma 185 accident notificationItem 26 · PDF · 1 page · 157 KBATC 3-attachment 4 cvg diagramItem 27 · PDF · 1 page · 235 KBATC 3-attachment 5 radar dataItem 28 · EXE · 27 KBStructures 7 - factual report of group chairmanItem 29 · PDF · 14 pages · 1.0 MBPowerplants 8-factual report of group chairmanItem 30 · PDF · 11 pages · 158 KBSystems 9-factual report of group chairmanItem 31 · PDF · 27 pages · 912 KBSystems 9-attachment 1-emergency handle on-site observationsItem 32 · PDF · 2 pages · 84 KBSystems 9-attachment 2-AIR tahoma CV-580 fuel system diagramItem 33 · PDF · 2 pages · 166 KBSystems 9-attachment 3-photograph of overhead fuel control panelItem 34 · PDF · 2 pages · 204 KBSystems 9-attachment 4-results of airplane boost pump testsItem 35 · PDF · 3 pages · 69 KBSystems 9-attachment 5-allison prop-jet convair service bulletin pjcb 10-21Item 36 · PDF · 4 pages · 1.9 MBSystems 9-attachment 6-convair 580 flight deck panel layoutItem 37 · PDF · 2 pages · 110 KBSystems 9-attachment 7-convair 580 center pedestal annunciator panelItem 38 · PDF · 2 pages · 248 KBSystems 9-attachment 8-results of center annunciator panel light bulb examinationItem 39 · PDF · 4 pages · 142 KBSystems 9-factual report of group chairman-addendum 1Item 40 · PDF · 4 pages · 189 KBSystems 9-factual report of group chairman-addendum 2Item 41 · PDF · 13 pages · 857 KBSystems 9-factual report of group chairman-addendum 3Item 42 · PDF · 5 pages · 113 KBSystems 9-factual report of group chairman-addendum 3-attachment 1Item 43 · PDF · 15 pages · 612 KBFlight data recorder 10-FDR specialist's factual reportItem 44 · PDF · 7 pages · 283 KBFlight data recorder 10-FDR specialist's factual report attachment i-csv file of FDR dataItem 45 · CSV · 2.3 MBMaintenance records 11 - factual report of group chairmanItem 46 · PDF · 5 pages · 90 KBMaintenance records 11 - attachment 1 - conformity check and acceptance manualItem 47 · PDF · 42 pages · 2.5 MBMaintenance records 11-attachment 2-serial number verificationItem 48 · PDF · 10 pages · 962 KBMaintenance records 11-attachment 3-C checkItem 49 · PDF · 24 pages · 3.0 MBMaintenance records 11 - attachment 4 - fuel filler cap inspectionItem 50 · PDF · 5 pages · 1.2 MBCockpit voice recorder 12-factual report of group chairmanItem 51 · PDF · 31 pages · 339 KBAircraft performance 13-study of group chairmanItem 52 · PDF · 23 pages · 1.7 MB

FAA reports on this event · 1

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