# NTSB ERA19LA096: Convair C131, N145GT, Atlantic Ocean (Atlantic Ocean), February 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: February 8, 2019, 12:16 local (17:16 UTC) - Place: Atlantic Ocean (Atlantic Ocean) - Coordinates: 25, -79 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.0000&lon=-79.0000&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report April 8, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 98965 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA096 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98965/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98965 - Page: https://openairdocs.org/ntsb/ERA19LA096 ## Probable cause The captain's decision to continue with the flight with a malfunctioning left engine propeller control and the subsequent loss of engine power on both engines for undetermined reasons, which resulted in ditching into the ocean. Contributing to the accident was the first officer's failure to challenge the captain's decision to continue with the flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Propeller system: propeller governor](https://openairdocs.org/ntsb-findings/01046122): Aircraft › Aircraft propeller/rotor · Failure (probable cause); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-findings/01046122/cases.md?model=2422903), [All aircraft, 16 cases](https://openairdocs.org/ntsb-findings/01046122/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2422903), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2422903), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2422903), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Copilot (probable cause); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2422903), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=2422903), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Enroute-cruise: Engine shutdown](https://openairdocs.org/ntsb-events/140); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-events/140/sequence.md?model=2422903), [All aircraft, 80 cases](https://openairdocs.org/ntsb-events/140/sequence.md) - [Emergency descent: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=2422903), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-flare/touchdown: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Convair C-131B, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=2422903), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis According to the first officer, during the first cargo flight of the day, the left engine propeller control was not working properly and the captain indicated that they would shut down the airplane and contact maintenance if the left engine propeller control could not be reset before the return flight. For the return flight, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed with the first officer as the pilot flying. The takeoff and initial climb were normal; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working and the power was stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and tried to stabilize the power on both engines. He leveled the airplane at 4,500 ft, canceled the instrument flight rules flight plan, and flew via visual flight rules direct toward the destination airport. The first officer suggested that they return to the departure airport, but the captain elected to continue as planned (The destination airport was located about 160 nautical miles from the departure airport). The first officer's postaccident statements indicated that he did not challenge the captain's decision. When the flight began the descent to 1,500 ft, the right engine began to surge and lose power. The captain and the first officer performed the engine failure checklist, and the captain feathered the propeller and shut down the engine. Shortly afterward, the left engine began to surge and lose power. The captain told the first officer to declare an emergency. The airplane continued to descend, and the airplane impacted the water "violently," about 32 miles east of the destination airport. The captain was unresponsive after the impact and the first officer was unable to lift the captain from his seat. Because the cockpit was filling rapidly with water, the first officer grabbed the life raft and exited the airplane from where the tail section had separated from the empennage. The first officer did not know what caused both engines to lose power. The airplane was not recovered from the ocean, so examination and testing to determine the cause of the engine failures could not be performed. According to the operator, the flight crew should have landed as soon as practical after the first sign of a mechanical issue. Thus, the crew should have diverted to the closest airport when the left engine propeller control stopped working and not continued the flight toward the destination airport. ## Factual narrative On February 8, 2019, at 1216 eastern standard time, a General Dynamics Convair 340 (C-131B), N145GT, was destroyed during a ditching in the Atlantic Ocean about 32 miles east of Miami-Opa Locka Executive Airport (OPF), Miami, Florida. The captain was fatally injured, and the first officer was seriously injured. The airplane was registered to and operated by Conquest Air, Inc., as a Title 14 Code of Federal Regulations Part 135 cargo flight. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The flight departed Lynden Pindling International Airport (MYNN), Nassau, Bahamas, at 1113.The accident occurred during a return trip to OPF. The first officer stated that, for the first flight of the day (from OPF to MYNN), the preflight inspection, engine start, taxi, and engine run-up were normal and that about 900 gallons of fuel was on board. The flight to MYNN was normal until the first officer, who was the pilot monitoring, attempted to adjust the left engine propeller control for the speed for cruise flight, yet there was no movement on the gauge, and the power was stuck at 2,400 rpm. The first officer tried to reset the propeller control circuit breaker but was unable to do so. The captain stabilized power on both engines, and the remainder of the flight to MYNN was uneventful. After the airplane landed, the captain asked the first officer to send a text message to maintenance control, but the message did not transmit. The captain told the first officer not to worry and indicated that, if they were unable to reset the propeller control on the ground during the engine run-up, then they would shut down the airplane and call maintenance. The first officer stated that, before the accident flight began, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed for OPF. The first officer was the pilot flying, and he stated that the airplane was operating normally during the takeoff and initial climb; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working, and the power was again stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and stabilized the power on both engines. He leveled the airplane at 4,500 ft, canceled the IFR flight plan, and flew via visual flight rules direct to OPF. The first officer suggested that they return to MYNN, but the captain wanted to continue to OPF (OPF was located about 160 nautical miles west-northwest of MYNN). The first officer indicated that he did not want to disagree with the captain's decision given the captain's "extensive" experience. The flight proceeded normally until the beginning of the descent (the first officer did not remember the altitude) to 1,500 ft, when the right engine began to surge andlose power. The first officer stated that the captain turned on both boost pumps and tried to stabilize the right engine with the mixture and throttle but that the engine began to backfire and shake "violently" with variations in the brake mean effective pressure (BMEP), fuel pressure, fuel flow indications, rpm, and manifold pressure. At that point, the flight crew performed the engine failure emergency checklist. As part of the checklist, the right engine was feathered, and the mixture was brought to the cutoff position. The first officer reported that, shortly afterward, the left engine also began to surge and shake "violently" with the same variations experienced after the right engine began to surge. At that point, the captain tried to control the left engine, and the first officer declared an emergency. The first officer stated that, as the captain maneuvered the airplane to ditch, the airplane impacted the water "violently." During the impact, the first officer struck his head hard on the instrument panel. The first officer unbuckled his harness and saw the captain slumped over in his seat and unresponsive. He tried to lift the captain from his seat but was not able to do so. The first officer realized that he needed to get out of the airplane when the water inside the cockpit was chest high. The first officer stated that he kicked open the cockpit door and saw that the tail had separated from the empennage. He grabbed the life raft and exited from the tail of the airplane. He was rescued by a US Coast Guard helicopter. The first officer stated that he did not know what caused the engines to lose power. According to the operator, "at the first sign of a mechanical malfunction the crew should have landed as soon as practicable." PERSONNEL INFORMATION The captain held an airline transport pilot certificate with ratings for airplane single- and multiengine land and instrument airplane. He held type ratings for the Boeing 727 and 737; the Convair 240, 340, and 440; and LR-JET. The operator reported that the captain had 23,000 hours total flight experience, of which 725 hours were in the accident airplane make and model. The captain also held a Federal Aviation Administration (FAA) first-class medical certificate dated January 22, 2019. The first officer held a commercial pilot certificate with ratings for airplane single- and multiengine land and instrument airplane. He held type ratings in the Convair 240, 340, and 440 (second-in-command privileges only). The operator reported that the first officer had 650 hours total flight experience, of which 305 hours were in the accident airplane. The first officer also held an FAA first-class medical dated August 25, 2018. AIRCRAFT INFORMATION The airplane was equipped with two Pratt & Whitney R-2800CB3 radial engines and two Hamilton Sunstrand 43E60-377 propellers that were being maintained under an approved aircraft inspection program. The airplane's last inspection was on the day before theaccident. At that time, the left engine had accrued 1,943 hours, the right engine had accrued about 417 hours, and the airframe had accrued about 12,701 hours. WRECKAGE AND IMPACT INFORMATION The left wing washed ashore. The rest of the airplane was not recovered from the ocean. Thus, the engines could not be examined and tested to determine the cause of the failures. ## Aircraft - Registration: [N145GT](https://openairdocs.org/deregistered/N145GT-2019-08-22), registration cancelled 2019-08-22, S/N 256, built 1955 (OpenAirDocs) - Reported make and model: Convair C131 (B) - Registry model: [Convair C-131B](https://openairdocs.org/model/convair-c-131b) (registry code 2422903) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-2800 series](https://openairdocs.org/engine/pratt-whitney-r-2800-series) (registry code 52026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 256 - Year built: 1955 - Airframe hours: 12701.2 - Engines: P&W R2800CB3 2400 horsepower reciprocating; P&W R2800CB3 2400 horsepower reciprocating - Damage: Destroyed - Flight: Part 135 - Operator: Conquest Air Inc - Registered owner: Conquest Air Inc - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, February 7, 2019 - Departed: NAS, Nassau, AOBF - Destination: OPF, Miami, FL - Flight plan: IFR - Equipment: ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1; last flight review August 9, 2018; seat: left; restraint: lap only; flight hours: 23,000 total, 725 in this make and model, 21,000 as pilot in command - Co-pilot; age 28; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, waiver time limited special; last flight review June 16, 2018; seat: right; restraint: 4-point; flight hours: 650 total, 305 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 3,600 ft broken - Temperature: 79 °F, dew point 63 °F - Altimeter: 30.20 inHg - Observed at: OPF, 32 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 20190208009989A](https://openairdocs.org/incident/20190208009989A), Feb 8, 2019: Convair C-131B, Miami, FL, Destroyed, 1 fatal. On 02-11-2019 at approximately 1000 inspector [privacy data omitted] and inspector [privacy data omitted] arrived at jackson memorial hospital and interviewed… ## Docket (7 files) The files NTSB released with the investigation on November 20, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98965. 8.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 511 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478160&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statement - First Officer (item 2, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478161&FileExtension=.PDF&FileName=Witness%20Statement%20-%20First%20Officer-Master.PDF - NTSB Record of Conversation - First Officer (item 3, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478162&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation%20-%20First%20Officer-Master.PDF - Fuel Receipts (item 4, .PDF, 518 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478163&FileExtension=.PDF&FileName=Fuel%20Receipts-Master.PDF - Maintenance Records (excerpt) (item 5, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478164&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpt)-Master.PDF - Photos (item 6, .PDF, 3 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478165&FileExtension=.PDF&FileName=Photos-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478166&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.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.