ERA09LA266

NTSB accident investigation · Douglas DC3 · San Juan, PR · April 26, 2009

Accident · No injuriesLimited investigationFinal report
Date
April 26, 2009, 04:15 local (08:15 UTC)
Place
San Juan, PR
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N136FSDouglas DC3
Defining event
Taxi-to runway: Fire/smoke (non-impact)
Weather
Visual (VMC) · Night
Status
Completed · report November 9, 2009
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
73730

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

Worn electrical wires and a fuel pressure indicating system hose, which resulted in a ground fire during taxi.

Findings · 3

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.

Electrical power systemAircraft › Aircraft systems · Damaged/degradedDouglas DC3: 1 caseAll aircraft: 48 casesProbable cause
Fuel system: fuel indication systemAircraft › Aircraft systems · Damaged/degradedDouglas DC3: 1 caseAll aircraft: 30 casesProbable cause
Misc hardware: hoses and tubesAircraft › Fluids/misc hardware · Not specifiedDouglas DC3: 1 caseAll aircraft: 40 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

During taxi to a runway, the instrument panel and cockpit floor erupted in flames. Examination of the wreckage revealed that the majority of the wires contained inside the main junction box had very little damage except for two wires that had insulation missing. The damage appeared to be associated with the routing of the two wires. Both wires were connected to the battery relay and ran through wires in and around the exposed terminal studs. Heat damage was noted on the insulation of wires and other components that were in contact with the exposed wires. The wires ran from the battery relay to the forward section of the cockpit, where the fire started. Due to the fire damage that consumed the cockpit, the examination was unable to determine what system the wires were associated with. Further examination revealed that the fuel pressure was a direct indicating system. Fuel traveled directly to the instruments in the cockpit via rigid aluminum lines routed on the right lower side of the fuselage, where more severe fire damage was noted. Review of maintenance records did not reveal any evidence of the fuel pressure indicating system lines and hoses having ever been replaced; however, they were only required to be replaced on an as-needed basis. The electrical system, instrument lines, and hoses through the nose compartment were required to be inspected on a Phase D inspection; the airplane's last Phase D inspection was completed about 9 months prior to the accident and the airplane had accrued 313.1 hours of operation since that inspection.

Factual narrative

On April 26, 2009, about 0415 eastern daylight time, a Douglas DC3, N136FS, operated by Four Star Aviation Inc., was substantially damaged after experiencing a cockpit fire during taxi at Luis Munoz Marin International Airport (TJSJ), San Juan, Puerto Rico. The certificated airline transport pilot, certificated commercial pilot, and two crewmembers were not injured. Visual meteorological conditions prevailed for the planned flight to Cyril E King Airport (TIST), Charlotte Amalie, United States Virgin Islands. A company flight plan was filed for the cargo flight conducted under the provisions of 14 Code of Federal Regulations Part 135. The flightcrew reported that they were transporting mail. While taxing on "juliet" taxiway to runway 10, the instrument panel and cockpit floor erupted in flames while smoke filled the cockpit. As the pilots were shutting down the engines, they became overwhelmed with fire and smoke, and quickly exited the airplane along with the two cargo handlers. The flightcrew added that they did not note any abnormal instrument readings or any anomalies during preflight inspection. The low-wing, tailwheel retractable-gear airplane, serial number 22405, was manufactured in 1942. It was powered by two Pratt and Whitney R-1830-90D, 1,200-horsepower engines. At the time of the accident, it was equipped with five seats due to a cargo configuration. The airplane had accumulated 19,952 total hours of operation at the time of the accident. Examination of the wreckage by Federal Aviation Administration (FAA) inspectors revealed that the fire was intense, from the bulkhead behind the pilots’ seats, to the front of the airplane. Everything was melted in that area, including instruments, switches, tubing, hoses, and skin. The inspectors noted more damage on the right side of the fuselage. They also noted that the left propeller was partially feathered. The inspectors observed that the majority of the wires, contained inside the main junction box, had very little damage, except for two wires that had insulation missing. The damage appeared to be associated with the routing of the two wires. Both wires were connected to the battery relay and they ran through wires in and around the exposed terminal studs. Heat damage was noted on the insulation of wires and other components that were in contact with the exposed wires. The wires ran from the battery relay to the forward section of the cockpit, where the fire started. Due to the fire damage, the inspectors were unable to determine what system the wires were associated with; however, one of the systems connected to the battery relay is the propeller feathering system. The inspectors added that the fuel pressure was a direct indicating system. Fuel traveled directly to the instruments via rigid aluminum lines routed on the right lower side of the fuselage. Review of maintenance records by the FAA inspectors revealed that the airplane was maintained under an FAA Approved Airplane InspectionProgram. The review did not reveal any evidence of the fuel pressure indicating system lines and hoses having ever been replaced; however, they were only required to be replaced on an as needed basis. Further review of maintenance records revealed that the electrical system, instrument lines, and hoses through the nose compartment were required to be inspected on a Phase D inspection. The airplane's last Phase D inspection was completed on July 14, 2008. The airplane had accrued 313.1 hours of operation, from the time of the last Phase D inspection, until the fire. The airplane's most recent inspection was a Phase B inspection, which was completed on March 22, 2009. The airplane had accumulated 40 hours of operation since that inspection. Review of the National Transportation Safety Board accident/incident database, and FAA service difficulty reports, did not reveal any similar events during the 5-year period preceding the accident.

Aircraft

Registration
N136FS
Reported as
Douglas DC3
Category
Airplane
Serial number
24405
Airframe hours
19,952
Engines
P & W R-1830-90D, 1,350 horsepower, reciprocatingP & W R-1830-90D, 1,350 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Part 135
Operator
Four Star Aviation Inc
Registered owner
Four Star Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 22, 2009 · 40 hours before
Departed
TJSJ · San Juan, PR
Destination
TIST · Charlotte Amali
Flight plan
Company VFR
Airport
TJSJ · Luis Munoz Marin International

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
69
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
December 28, 2008
Seat
Left
Flight hours
50,233 total · 7,000 in this make and model · 48,800 as pilot in command · 150 in the last 90 days · 50 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
29
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 22, 2008
Seat
Right
Flight hours
957 total · 204 in this make and model · 650 as pilot in command · 100 in the last 90 days · 24 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
100° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 70 °F
Altimeter
30.04 inHg
Observed at
TJSJ

Docket · 4

The files NTSB released with the investigation on June 26, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 MB in all.