DCA91MA033

NTSB accident investigation · Embraer EMB-120RT · Brunswick, GA · April 5, 1991

Accident · FatalClass 1 · MajorFinal report
Date
April 5, 1991, 14:51 local (19:51 UTC)
Place
Brunswick, GA
Injuries
23 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N270ASEmbraer EMB-120RT
Weather
Visual (VMC) · Day
Status
Completed · report August 5, 1993
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19910405009019A
Case key
15951

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 loss of control in flight as a result of a malfunction of the left engine propeller control unit which allowed the propeller blade angles to go below the flight idle position. Contributing to the accident was the deficient design of the propeller control unit by hamilton standard and the approval of the design by the federal aviation administration. The design did not correctly evaluate the failure mode that occurred during this flight, which resulted in an uncommanded and uncorrectable movement of the blades of the airplane's left propeller below the flight idle position. (NTSB report AAR-92/03)

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.

Airframe/component/system failure/malfunctionApproach
Propeller system/accessories,prop control unit - inadequateCause
Acft/equip,inadequate designManufacturerFactor
Inadequate substantiation processFaa(organization)Factor
Propeller system/accessories,prop control unit - failure,partialCause
Loss of control - in flightApproach
In flight collision with terrain/waterApproach

Analysis

Witnesses reported that the airplane suddenly turned or rolled left until the wings were perpendicular to the ground. The airplane then fell in a nose-down attitude. Exam of the left prop components indicated a blade angle of about 3 deg, while the left prop control unit (pcu) ballscrew position was consistent with a commanded blade angle of 79.2 deg. Extreme wear on the pcu quill spline teeth, which normally engaged the titanium-nitrided splines of the prop transfer tube, was found. The titanium-nitrided surface was much harder and rougher than the nitrided surface of the quill. Therefore, the transfer tube splines acted like a file and caused abnormal wear of the gear teeth on the quill. Wear of the quill was not considered during the certification of the propeller system.

Aircraft

Registration
N270AS
Reported as
Embraer EMB-120RT
Category
Airplane
Serial number
120-218
Airframe hours
816
Engine
P&W PW-118, 1,800 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Atlantic Southeast Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 1, 1991 · 26 hours before
Departed
ATL · Atlanta, GA
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
11,724 total · 5,720 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 10 knots
Visibility
7 statute miles
Lowest ceiling
10,000 ft broken
Temperature
79 °F, dew point 70 °F
Altimeter
30.00 inHg
Observed at
BQK, 2 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.