# NTSB DCA84AA033: Britten-Norman BN-2A Islander, N589SA, Vieques, PR, August 2, 1984

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Final report
- Date: August 2, 1984, 08:05 local (12:05 UTC)
- Place: Vieques, PR
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 9 fatal
- Status: Completed
- Report: Board-adopted at Board Meeting
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 15812
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA84AA033
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15812/pdf
- Board report AAR8508 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8508.pdf
- Page: https://openairdocs.org/ntsb/DCA84AA033

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(partial) - nonmechanical, takeoff - initial climb
  - procedures/directives - not followed, company/operator management (contributing factor)
  - inadequate surveillance of operation, faa(organization) (contributing factor)
  - aircraft weight and balance - improper, pilot in command (contributing factor)
  - maintenance,service of aircraft/equipment - improper, ground personnel (contributing factor)
  - aircraft preflight - inadequate, pilot in command (contributing factor)
  - fluid,fuel - water (contributing factor)
- Loss of control - in flight, takeoff - initial climb
  - emergency procedure - improper, pilot in command (cause)
  - qualification, pilot in command (contributing factor)
  - propeller feathering - not performed, pilot in command
  - raising of flaps - not performed, pilot in command
  - airspeed(vmc) - not maintained, pilot in command (cause)
  - lack of total experience in kind of aircraft, pilot in command (contributing factor)
  - inadequate training, company/operator management (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled

## Analysis

A WITNESS REPORTED HE HEARD AN APPARENT ENG PROBLEM AFTER THE ACFT TOOK OFF & BEGAN A LEFT TURN FOR A X-WIND DEPARTURE. REPORTEDLY, THE ACFT OSCILLATED, THEN AFTER REGAINING SOME LOST ALT, IT BANKED ABRUPTLY TO THE LEFT, NOSED DOWN, & SUBSEQUENTLY, CRASHED IN THE OCEAN IN A LEFT WING LOW, NOSE DOWN ATTITUDE. AN INVESTIGATION REVEALED EVIDENCE THE LEFT ENG HAD LOST POWER DUE TO WATER CONTAMINATION. WATER WAS FOUND IN THE FUEL STORAGE TANK AS WELL AS IN ANOTHER ACFT THAT HAD BEEN REFUELED FROM THE SAME TANK. THE LEFT PROP HAD NOT BEEN FEATHERED & THE FLAPS WERE FOUND FULL DOWN. THE PLT HAD BEEN DESIGNATED FOR 'ON-DEMAND' FLTS, BUT HE WAS NOT CERTIFIED FOR 'SCHEDULED COMMUTER' FLTS. THE COMPANY HAD DESIGNATED THIS AS AN ON-DEMAND FLT RATHER THAN AN EXTRA-SECTION SCHEDULED COMMUTER FLT. THERE WAS EVIDENCE THE ACFT WAS LOADED 600 TO 700 LBS OVER THE MAX LIMIT & UP TO 5 INCHES BEHIND THE AFT CG LIMIT. FAA SURVEILLANCE OF THE COMPANY OPERATIONS WAS NOT EFFECTIVE IN IDENTIFYING PRBLMS. THE STORAGE TANK FILLER CAP (IN A WELL AREA) WAS NOT WATER TIGHT.

## Aircraft

- Registration: N589SA (not matched to a registry record)
- Reported make and model: Britten-Norman BN-2A ISLANDER (BN-2A ISLA)
- Category: Airplane
- Serial number: 38
- Engines: LYCOMING O-540-E4C5 260 horsepower reciprocating
- Damage: Destroyed
- Flight: Part 135
- Operator: Vieques Air Link, Inc.
- Registered owner: Vieques Air Link, Inc
- Airworthiness certificate: Standard, Utility
- Departed: VQS
- Destination: STX, ST CROIX
- Flight plan: Company VFR
- Airport: VQS, Vieques, runway 9, 2,500 × 75 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 21; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 723 total, 71 in this make and model, 142 in the last 90 days, 31 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 90° at 10 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 88 °F, dew point 73 °F

## 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 19840802076919A](https://openairdocs.org/incident/19840802076919A), Aug 2, 1984: Bnorm BN2A6, Vieques, Puerto Rico, Destroyed, 8 fatal. Power lost on left engine due to water in fuel, over gross with aft CG at takeoff. Stalled and impacted in ocean.

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.

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