# NTSB DEN03TA079: McDonnell Douglas A-4N, N263WL, Salt Lake City, UT, May 10, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: May 10, 2003, 12:09 local (18:09 UTC) - Place: Salt Lake City, UT - Coordinates: 40.893054, -112.276107 - Nearby events: https://openairdocs.org/map.md?lat=40.8931&lon=-112.2761&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 8, 2005 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 56966 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN03TA079 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56966/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56966 - Page: https://openairdocs.org/ntsb/DEN03TA079 ## Probable cause The lose of engine power during descent due to the in-flight collision with a bird which FOD damaged the engine and subsequently melted the turbine section. A contributing factor was the airplane's malfunctioning ejection seat. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, descent - object - bird(s) (cause) - Loss of engine power, descent - powerplant - foreign object damage (cause) - powerplant - melted (cause) - Miscellaneous/other, descent - emergency - bail-out/emergency ejection - performed, pilot in command - fuselage,seat - malfunction (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis The airplane was a former military (non-certificated) aircraft which was under contract to the U.S. Army. It was descending over the Great Salt Lake for landing at Hill Air Force Base when the engine ingested a bird. Subsequently the engine was heavily FOD damaged, and the turbine section was melted. The pilot ejected from the airplane, but the ejection seat system malfunctioned and the pilot was fatally injured. The airplane impacted the lake. The airplane had been contracted and built for the Israeli Defense Force in 1974. The maintenance log books and physical evidence indicated that they had made modifications to the ejection seat assembly. Naval Air Station (NAVAIR DEPOT), Jacksonville, Florida, personnel evaluated the ejection seat system and determined that the left hand coupling assembly (which has very critical parameters for proper operation) had not separated as designed. The NAVAIR DEPOT personnel could not determine the reason the left hand coupling assembly did not operate properly, as the airplane's cockpit was not recovered from the Great Salt Lake. ## Factual narrative HISTORY OF FLIGHT On May 10, 2003, at approximately 1209 mountain daylight time, a former military non-certificated McDonnell Douglas A-4N Skyhawk, N263WL, was destroyed when it impacted the Great Salt Lake following a loss of engine power near Salt Lake City, Utah. The airline transport pilot, the sole occupant on the airplane, was fatally injured. Advanced Training Systems International (ATSI), Inc., Mesa, Arizona, was operating the airplane, under contract to the United States Government (U.S. Army Big Crow Program Office), as a public use flight. Visual meteorological conditions prevailed for the cross-country flight that originated from Mesa, Arizona, at approximately 1100. The pilot was flying the number two aircraft, in a flight of three, under an instrument flight rules (IFR) flight plan. The planned destination was Hill Air Force Base, Ogden, Utah. According to ATSI, the airplane was number two in a flight of three fighters that were repositioning from Williams Gateway Airport, Mesa, Arizona, to Cold Lake Military Airport, Cold Lake, Alberta, Canada, to support the Canadian military forces in training. The lead pilot reported that the flight was uneventful until the descent into Hill Air Force Base. He said that the flight had leveled off at 12,000 feet on a heading of 340 degrees with an indicated airspeed of 300 knots. Then, number three observed a "fairly thick vapor trail (white) emanate from the center fuselage of the aircraft [number two] and then stop. Duration of the event was less than 2 seconds. I was about to query the pilot about it when he reported, 'I'm having engine problems'." The lead pilot instructed the pilot to proceed directly to Hill Air Force Base on an approximate heading of 060 degrees. The lead pilot further suggested that the pilot drop his external fuel tanks and try to stay in visual flight conditions. After approximately one minute, the accident airplane had slowed to approximately 200 knots and its rate of descent was increasing. The lead pilot said, "are you in manual fuel control?" The pilot said, "not yet, I've got 200 knots." In his next transmission he said, "I've got 30% [power]". Lead asked "rat [an emergency electrical generating device] out?" The pilot responded "yes, I'm starting to lose flight controls." Lead said, "you have the manual flight control handle." The pilot said, "I hmm have to get out." Approximately 2 to 3 seconds later, the nose of the airplane came up [to reduce the descent rate and airspeed], and the pilot ejected from the airplane at approximately 1,000 to 1,500 feet above the lake. Both witness pilots reported that the ejection seat appeared to veer immediately left after the seat cleared the cockpit. The lead pilot said that the pilot/seat separation sequence appeared to be "fairly violent (unstable) and [the] pilot and [the] seat stayed very close together throughout the rest of the free-fall." He said that the airplane remained wings level, slowly nosed over, and impacted the water. He said that 3 to 4 seconds later, the pilot and ejection seat simultaneously impacted the water "very close together." No parachute was observed. A Lifeguard helicopter came to the scene, and with the aid of two Antelope Island State Park rangers, in a boat, retrieved the pilot's body from the lake. PERSONAL INFORMATION ATSI reported that the pilot had approximately 10,500 hours of flight experience, and a current first class medical dated January 2, 2003. The pilot had flown A-4 Skyhawks for the Navy; at the time of the accident, he was employed as a pilot for Delta Airlines. The pilot had a letter of authorization (LOA), dated November 27, 2002, to act as pilot in command of all Douglas A-4 Skyhawk models. At the time of the accident, he was current in all ATSI required training. AIRCRAFT INFORMATION The airplane (Bureau Number 159523) was a single engine, single seat, delta-platform wing, retired military fighter manufactured by the McDonnell Douglas Aircraft Company, for the Israeli Defense Force (IDF). It had an unofficial manufacturing date of October 18, 1974. The airplane had a gross weight limitation of 24,500 pounds, and was powered by a Pratt and Whitney J52 P-408 gas turbine engine with 11,200 pounds of thrust. The U.S. Navy originally specified that the A-4 Skyhawk's airframe have a 7,500-hour life; they later changed that to a 12,000-hour life. ATSI reported that the accident airplane, which they purchased from the IDF in early 2001, had accumulated a total of 2,664 flight hours. The airplane was equipped with a McDonnell Douglas, Escapac, 1G-3 ejection seat (S/N A18-257), which was the same model ejection seat that it left the factory with. This seat was capable of functioning properly with the airplane stationary on the ground, i.e., zero airspeed-zero altitude capability. A Navy ejection seat engineer stated that the 1G-3 Ejection Seat is ideal for low altitude low speed ejections (below 8,000 feet and airspeed less than 250 knots). ATSI reported that all routine and preventive maintenance on the aircraft, including the ejection seat and parachute, were current at the time of the accident. METEOROLOGICAL INFORMATION At 1211, the weather conditions at Salt Lake City International Airport (elevation 4,227 feet), Salt Lake City, Utah, approximately 100 degrees, 18 nautical miles (nm) from the accident site, were as follows: wind 120 degrees at 7 knots; visibility 10 statute miles; cloud condition 1,200 feet few, 3,400 feet broken, 5,500 feet broken; temperature 44 degrees Fahrenheit; dew point 41 degrees Fahrenheit; altimeter setting 30.08 inches. WRECKAGE AND IMPACT INFORMATION The wreckage was located in the Great Salt Lake (N40 degrees, 53', 45"; W112 degrees, 16', 45"; elevation 4,206 feet), Salt Lake City, Utah. Retrieval of the wreckage took considerable effort due to poor underwater visibility, high saline densities (approximately 17 times more saline than the Pacific Ocean), and unknown depths of silt deposits; the water depth was approximately 22 feet. Pieces of the empennage and the engine were lifted from the lake on June 3, 2003; the ejection seat was retrieved on June 7, 2003. MEDICAL AND PATHOLOGICAL INFORMATION The State of Utah's Department of Health, Office of the Medical Examiner, Salt Lake City, Utah, performed an autopsy on the pilot on May 10, 2003. The medical examiner determined that the pilot died from blunt force to the neck. The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report (#200300132001), carbon monoxide and cyanide tests were not performed. The vitreous was tested for ethanol with negative results; the urine was tested for drugs with negative results. TESTS AND RESEARCH The airplane's Pratt and Whitney J52 P-408 engine (Serial Number 686484) with its fuel control unit were sent to the Naval Air Station (NAVAIR DEPOT), Jacksonville, Florida, for teardown and evaluation. Their investigation revealed that the engine was FOD [Foreign Object Damage] damaged, and evidence of feather and organic material was found in/on the turbine nozzle support, turbine case, turbine vanes and blades, and exhaust case. Feather material was also found inside solidified, pooled metal. The turbine section exhibited substantial turbine blade melting throughout, with evidence of metal spattering, dripping, and pooling. Several fuel lines from the accident airplane and two sister aircraft were sent to Wright-Patterson Air Force Base's, Materials Integrity Branch for evaluation. After visual, nondestructive, and fractographic examination, seven of the hoses (including all the accident aircraft samples) revealed various characteristics that did not meet Mil-DTL-8794 and Mil-DTL-8795 specifications. Additionally, a laboratory technician who assisted in the work said "even th ## Aircraft - Registration: [N263WL](https://openairdocs.org/deregistered/N263WL-2004-04-15), registration cancelled 2004-04-15, S/N 159523 (OpenAirDocs) - Reported make and model: McDonnell Douglas A-4N - Registry model: [Mcdonnell Douglas A4N](https://openairdocs.org/model/mcdonnell-douglas-a4n) (registry code 3021019) (OpenAirDocs) - Category: Airplane - Serial number: 159523 - Airframe hours: 2664 - Engines: Pratt & Whitney J52 P-408 11200 lbs thrust turbo jet - Damage: Destroyed - Flight: Positioning, Public use - Registered owner: Advanced Training Systems International Inc. - Airworthiness certificate: Special, Experimental (Special) - Last inspection: AAIP, May 4, 2003, 2 hours before - Departed: IWA, Mesa, AZ - Destination: HIF, Ogden, UT - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: fatal; airline transport, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review November 20, 2002; seat: single; toxicology performed; flight hours: 10,500 total, 199 in this make and model, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 3,400 ft broken - Temperature: 45 °F, dew point 41 °F - Altimeter: 30.07 inHg - Observed at: SLC, 18 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 (OpenAirDocs). - [Accident 20030510008039A](https://openairdocs.org/incident/20030510008039A), May 10, 2003: Doug A4N, Syracuse, UT, Destroyed, 1 fatal. (-23) The aircraft departed from williams gateway airport enroute to cold lake, Canada with two other A4'S with a planned fuel stop at hill afb. After… ## Docket (10 files) The files NTSB released with the investigation on April 5, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56966. 41.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400591&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400592&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Record of Telephone Conversation (item 3, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40228791&FileExtension=.PDF&FileName=Record%20of%20Telephone%20Conversation-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 4, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40228793&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Weather Reports and Records (item 5, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40228794&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Reports Supporting the Investigation (section 1) (item 6, .PDF, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400597&FileExtension=.PDF&FileName=Reports%20Supporting%20the%20Investigation%20(section%201)-Redacted.PDF - Reports Supporting the Investigation (section 2) (item 7, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400598&FileExtension=.PDF&FileName=Reports%20Supporting%20the%20Investigation%20(section%202)-Redacted.PDF - Reports Supporting the Investigation (section 3) (item 8, .PDF, 19.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400610&FileExtension=.PDF&FileName=Reports%20Supporting%20the%20Investigation%20(section%203)-Redacted.PDF - Reports Supporting the Investigation (section 4) (item 9, .PDF, 10.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400601&FileExtension=.PDF&FileName=Reports%20Supporting%20the%20Investigation%20(section%204)-Redacted.PDF - Toxicological Report (item 10, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400599&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.