DCA12FA051

NTSB accident investigation · Convair 440 - NO Series · San Juan, PR · March 15, 2012

Accident · FatalClass 1 · FieldFinal report
Date
March 15, 2012, 07:38 local (11:38 UTC)
Place
San Juan, PR
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N153JRConvair 440 - NO Series
Defining event
Approach: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report February 3, 2015
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20120315006989A
Case key
83140

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 flight crew's failure to maintain adequate airspeed after shutting down the right engine due to an in-flight fire in one of the right augmentors. The failure to maintain airspeed resulted in either an aerodynamic stall or a loss of directional control.

Findings · 8

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Flight crewConvair 340: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedConvair 340: 1 caseAll aircraft: 1,681 casesProbable cause
Engine exhaustAircraft › Aircraft power plant · Not specifiedConvair 340: 1 caseAll aircraft: 56 casesProbable cause
Documentation/record keepingOrganizational issues › Support/oversight/monitoring · OperatorConvair 340: 1 caseAll aircraft: 12 cases
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorConvair 340: 1 caseAll aircraft: 61 cases
Water injectionAircraft › Aircraft power plant · Not used/operatedConvair 340: 1 caseAll aircraft: 1 case
Propeller system: propeller feather/reversingAircraft › Aircraft propeller/rotor · Not used/operatedConvair 340: 1 caseAll aircraft: 26 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/04 On March 15, 2012, about 0740 Atlantic standard time, a Convair CV-440-38, N153JR, operated by Fresh Air, Inc., crashed into a lagoon about 1 mile east of the departure end of runway 10 at Luis Muñoz Marín International Airport (SJU), San Juan, Puerto Rico. The two pilots died, and the airplane was destroyed by impact forces. The airplane was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 1251 as a cargo flight. Visual meteorological conditions prevailed at the time of the accident, and a visual flight rules flight plan was filed. The flight had departed from runway 10 at SJU destined for Princess Juliana International Airport, St. Maarten. Shortly after takeoff, the first officer declared an emergency, and then the captain requested a left turn back to SJU and asked the local air traffic controllers if they could see smoke coming from the airplane (the two tower controllers noted in postaccident interviews that they did not see more smoke than usual coming from the airplane). The controllers cleared the flight to land on runway 28, but as the airplane began to align with the runway, it crashed into a nearby lagoon (Laguna La Torrecilla).

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/04 On March 15, 2012, about 0740 Atlantic standard time, a Convair CV-440-38, N153JR, operated by Fresh Air, Inc., crashed into a lagoon about 1 mile east of the departure end of runway 10 at Luis Muñoz Marín International Airport (SJU), San Juan, Puerto Rico. The two pilots died, and the airplane was destroyed by impact forces. The airplane was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 1251 as a cargo flight. Visual meteorological conditions prevailed at the time of the accident, and a visual flight rules flight plan was filed. The flight had departed from runway 10 at SJU destined for Princess Juliana International Airport, St. Maarten. Shortly after takeoff, the first officer declared an emergency, and then the captain requested a left turn back to SJU and asked the local air traffic controllers if they could see smoke coming from the airplane (the two tower controllers noted in postaccident interviews that they did not see more smoke than usual coming from the airplane). The controllers cleared the flight to land on runway 28, but as the airplane began to align with the runway, it crashed into a nearby lagoon (Laguna La Torrecilla).

Aircraft

Registration
N153JR
Reported as
Convair 440 - NO Series (NO SERIES)
Category
Airplane
Serial number
117
Engines
Pratt & Whitney R-2800-103W, reciprocatingPratt & Whitney R-2800-52W, reciprocating
Damage
Destroyed
Fire
In-Flight
Flight
Part 125
Operator
Fresh Air, Inc.
Registered owner
Fresh Air, Inc.
Airworthiness certificate
Standard, Transport
Departed
SJU · San Juan, PR
Destination
SXM · Princess Julian, PR
Flight plan
VFR
Airport
SJU · Luis Munoz Marin Intl, runway 28, 8,016 × 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
65
Injuries
Fatal
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
22,586 total · 9,000 in this make and model
Role
Co-pilot
Age
44
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Right
Flight hours
2,716 total · 700 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 5 knots
Visibility
10 statute miles
Temperature
75 °F, dew point 64 °F
Altimeter
30.09 inHg
Observed at
TJSJ, 2 nm away

Docket · 57

The files NTSB released with the investigation on September 12, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 16 photos · 3.1 MBOperations 2 - Attachment 1 - Interview SummariesItem 2 · .PDF · 1.1 MBOperations 2 - Attachment 2 - Crew RecordsItem 3 · .PDF · 17.0 MBOperations 2 - Attachment 3 - Weight and BalanceItem 4 · .PDF · 13 photos · 2.3 MBOperations 2 - Attachment 4 - Convair Service Bulletin 340-144BItem 5 · .PDF · 10.5 MBOperations 2 - Attachment 5 – Fueling RecordsItem 6 · .PDF · 1.2 MBOperations 2 - Attachment 6 - WeatherItem 7 · .PDF · 2 photos · 243 KBOperations 2 - Attachment 7- Holsum DocumentsItem 8 · .PDF · 4 photos · 5.9 MBOperations 2 - Attachment 8 - Air Traffic ControlItem 9 · .PDF · 10 photos · 10.7 MBOperations 2 - Attachment 9 – Airport Emergency ResponseItem 10 · .PDF · 647 KBOperations 2 - Attachment 10- AirportItem 11 · .PDF · 1.1 MBOperations 2 - Attachment 11 – Fresh Air General Operations ManualItem 12 · .PDF · 12.1 MBOperations 2 - Attachment 12 – Fresh Air Accident Aircraft ChecklistsItem 13 · .PDF · 3.4 MBOperations 2 - Attachment 13 – DC4 Flight Log PageItem 14 · .PDF · 893 KBOperations 2 - Attachment 14 – Minimum Equipment ListItem 15 · .PDFOperations 2 - Attachment 15 – Evidence Control FormsItem 16 · .PDF · 233 KBOperations 2 - Attachment 16 – San Juan FSDO Organizational ChartItem 17 · .PDF · 260 KBOperations 2 - Attachment 17 – South Florida CMOItem 18 · .PDF · 4.0 MBOperations 2 - Attachment 18 – Fresh Air Operations SpecificationsItem 19 · .PDF · 2.3 MBOperations 2 - Attachment 19 - Fresh Air POI Work PlanItem 20 · .PDF · 1.1 MBOperations 2 - Attachment 20 – Fresh Air PTRS InformationItem 21 · .PDF · 5.5 MBOperations 2 - Attachment 21 – PTRS Procedures Manual ExcerptsItem 22 · .PDF · 513 KBOperations 2 - Attachment 22 – FAA Order 8900.1 - PTRS Codes and Job AidsItem 23 · .PDF · 27.4 MBOperations 2 - Attachment 23 – FAA Order 1800.56LItem 24 · .PDF · 5.7 MBOperations 2 - Attachment 24 – Flight Standards Inspector Resource ProgramItem 25 · .PDF · 5.9 MBOperations 2 - Attachment 25 – FAA Enhanced Vital Information Database (excerpts)Item 26 · .PDF · 587 KBOperations 2 - Attachment 26 - FAA ResponsesItem 27 · .PDF · 1.7 MBOperations 2 - Attachment 27 - Fresh Air SubpoenaItem 28 · .PDF · 197 KBOperations 2 - Attachment 28 – Previous Convair Fire AccidentItem 29 · .PDF · 1.9 MBOperations 2 - Attachment 29 – Tiger Contract Cargo Operations SpecificationsItem 30 · .PDF · 326 KBOperations 2 - Attachment 30 - Crew 72 hourItem 31 · .PDF · 1.6 MBOperations 2 - Attachment 31 – Convair 340 Airplane Flight ManualItem 32 · .PDF · 13.2 MBMaterials Laboratory 15 - Factual Report of Fire Group Chairman 13-007Item 33 · .PDF · 23 photos · 4.0 MBAirworthiness Factual Report of Group ChairmanItem 34 · .PDF · 58 KBAirworthiness Appendix A - FiguresItem 35 · .PDF · 1.9 MBAirworthiness - Attachment 1 - Survey DataItem 36 · .PDF · 1.2 MBRecord of Conversation - GomezItem 37 · .PDF · 46 KBAircraft Performance 13 - Airplane Performance StudyItem 38 · .PDF · 1.0 MBMaintenance Records 11 - Attachment 1 - Operating CertificateItem 39 · .PDF · 34 KBMaintenance Records 11 - Attachment 2 - Inspection ProgramItem 40 · .PDF · 140 KBMaintenance Records 11 - Attachment 3 - Airworthiness DirectivesItem 41 · .PDF · 332 KBMaintenance Records 11 - Attachment 4 - Service Difficulty ReportsItem 42 · .PDF · 92 KBMaintenance Records 11 - Attachment 5 - Aircraft Flight LogsItem 43 · .PDF · 1.1 MBMaintenance Records 11 - Attachment 6 - Convair Service BulletinItem 44 · .PDF · 2.5 MBMaintenance Records 11 - Factual Report of Group ChairmanItem 45 · .PDF · 81 KBPowerplants 8 - Factual Report of Group Chairman with 46 Photos and 2 FiguresItem 46 · .PDF · 6.0 MBPowerplants 8 - Attachment 1 - Propeller SN A33141 Log Book Entry Sticker and Maintenance & Service History PagesItem 47 · .PDF · 276 KBPowerplants 8 - Attachment 2 - Propeller SN 191271 Log Book Entry Sticker and Maintenance & Service History PagesItem 48 · .PDF · 459 KBPowerplants 8 - Attachment 3 - Type Certificate 5E-8 for military R-2800-103W and R-2800-52W enginesItem 49 · .PDF · 329 KBPowerplants 8 - Attachment 4 - Type Certificate E-264-9 for the civilian P&W dual wasp CB3, CB4, CB 16, and CB17 model enginesItem 50 · .PDF · 57 KBPowerplants 8 - Attachment 5 - FAA Authorization Release Certificate FAA Form 8130-3, Airworthiness Approval Tag, propeller, PN 43E60-377/6895A-8, SN A133141Item 51 · .PDF · 261 KBPowerplants 8 - Attachment 6 - Propeller SN A133141 log bookItem 52 · .PDF · 116 KBPowerplants 8 - Attachment 7 - FAA Authorization Release Certificate FAA Form 8130-3, Airworthiness Approval Tag, propeller, PN 43E60-377/6895A-8, SN 191271Item 53 · .PDF · 265 KBPowerplants 8 - Attachment 8 - Propeller SN 191271 log bookItem 54 · .PDF · 622 KBPowerplants 8 - Attachment 9 - NAVAIR 01-05MRB-1 – Automatic Feathering System DescriptionItem 55 · .PDF · 330 KBPowerplants 8 - Attachment 10 - United CV-340 Instruction Manual – Automatic Feathering System DescriptionItem 56 · .PDF · 164 KBPowerplants 8 - Attachment 11 - NAVAIR 01-05MRB-1 – Throttle Quadrant DescriptionItem 57 · .PDF · 249 KB

FAA reports on this event · 1

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