LAX97FA082

NTSB accident investigation · Fairchild SA227-AC · Bullhead City, AZ · January 5, 1997

Accident · Minor injuriesField investigationFinal report
Date
January 5, 1997, 12:43 local (19:43 UTC)
Place
Bullhead City, AZ
Injuries
2 minor, 19 uninjured
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N165SWFairchild SA227-AC
Weather
Visual (VMC) · Day
Status
Completed · report March 25, 1998
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19970105000149A
Case key
29602

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

failure of the pilot(s) to use 'override' ignition as prescribed by checklist procedures during an encounter with icing conditions, which subsequently led to ice ingestion and dual engine flame-outs. Factors related to the accident were: the adverse weather (icing) conditions, the accumulation of airframe/engine ice, and lack of suitable terrain in the emergency landing area.

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.

In flight encounter with weatherCruise
Weather condition - icing conditionsFactor
Airframe - iceFactor
Loss of engine power(total) - nonmechanicalApproach
All engines
Ignition system,auto re-light system - not installed
Aircraft/equipment inadequate
Ignition system,igniter - not activated
Checklist - not followedPilot in commandCause
Miscellaneous,engine - ice ingestionCause
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency landing
Terrain condition - none suitableFactor

Analysis

After executing a missed approach at the Grand Canyon Airport, the pilots diverted to the Bullhead City Airport. The pilots reported that minimal icing conditions were encountered with about 1/8 inch of ice accumulating on the aircraft wings. The pilots stated they cycled the deice boots to shed ice. They did not observe ice on the propeller spinners, and they did not activate the engines' 'override' ignition systems, as required by the airplane's flight manual. Use of 'override' ignition was required for flight into visible moisture at or below +5 degrees Celsius (+41 degrees Fahrenheit) to prevent ice ingestion/flameouts. Subsequently, both engines flamed out as the airplane was on about a 3 mile final approach for landing with the landing gear and flaps extended. The aircraft was destroyed during an off-airport landing.

Factual narrative

History of flight

On January 5, 1997, at 1243 hours mountain standard time, a Fairchild SA-227-AC, N165SW, serial no. AC-514, collided with terrain about 1.5 miles south of the Bullhead City, Arizona, airport following the near simultaneous flame out of both engines. The aircraft was operated by FNG Aviation, d.b.a. Skylink Charters of Santa Monica, California, as an on-demand air taxi flight under 14 CFR Part 135. The aircraft was destroyed in the ground collision sequence. The two pilots sustained minor injuries, and the 19 passengers were uninjured. Visual meteorological conditions prevailed at the departure point, and a VFR/IFR flight plan was filed.

The flight originated at Long Beach, California, at 0900 Pacific standard time as a non-stop flight to the Grand Canyon in Arizona. Instrument meteorological conditions prevailed at the Grand Canyon and the aircraft was cleared for a localizer instrument approach. The weather was below landing minimums and the pilot executed a missed approach. He then diverted to the company designated alternate airport at Bullhead City.

Both pilots reported they had experienced minimal icing at the Grand Canyon. The captain estimated about 1/8 inch had accumulated on the wings. The pilots stated that they exercised the deice boots one time. They also stated that they never used override ignition during the flight.

On January 6, 1997, the cockpit voice recorder (CVR), the only recorder onboard, was sent to the Safety Board's Laboratory for a readout. The tape contained 32 minutes of recording, starting about the time the aircraft was leaving the Grand Canyon for Bullhead City.

According to the CVR, at 6.5 miles out on final approach for runway 34, the aircraft was at 150 knots. At 1239:54, the captain called for full flaps and requested the first officer advise the tower that they were slowing to 130 knots for traffic.

At 1240:41, both engines started spooling down. At 1240:44, the captain said "dual failure. Feather, feather 'em, feather 'em." The first officer asked which engine? The captain stated "both of 'em." At 1241:48, the first officer stated "no attempts on re-starts." The captain responded "yes, go through it. Go through the check list quick." At 1243, the CVR recording ended.

According to a postaccident interview of the first officer; there were no mechanical malfunctions encountered during the entire flight. No annunciator lights were illuminated, and all systems were (ok).

A review of the Fairchild SA-227 FAA Approved Flight Manual (AFM) revealed that there are no procedures in the AFM that addresses a dual engine flameout.

Personnel information

Captain

The captain was hired on September 7, 1994, and at the time of the accident he reported a total flight time of 3,200 hours with 300 hours in type. The captain was FAA type rated in the SA-227 aircraft. Examination of the pilot training records reveal that on September 17, 1993, he attended a 19.5 hour Allied Signal Aerospace TPE331 Engine Pilot Familiarization Course. On May 18, 1996, the pilot was awarded a certificate after 45 hours of ground school training on the Metro III / SA227 aircraft. On June 9,1996, the captain successfully passed an Airman Competency/Proficiency Check Ride for Part 135.293, 135.297, and 135.299.

First officer

The first officer was hired on September 6, 1996, and at the time of the accident he reported a total flight time of 640 hours with 56 hours in the make and model. The records indicate that since the hire date he has received about 93 hours of training recommended in the FNG Aviation training manual on the Fairchild SA-226 and SA-227 aircraft and the general FAA approved operations manual of procedures. The records also indicate that he successfully passed two Airman Competency/Proficiency Check Rides for second-in-command Part 135.293 in the SA-226/SA-227 aircraft by the operators chief pilot, both in September 1996.

Aircraft information

The aircraft was being maintained on a continuous airworthiness program. The last phase inspection occurred on December 27, 1996, 20.7 hours prior to the accident. The total time on the airframe was listed as 25,110 hours. According to the pilots, there were no unresolved maintenance items.

At the accident site the Hobbs meter indicated 4,023.8 hours, and the fuel used meter indicated 1,385 pounds.

Engine examinations

Accident site engine examinations were conducted by the Safety Board with engine manufacturer representatives prior to removal of the wreckage to a secure storage area.

Prior to the beginning of the formal examination, the FAA participants from the Scottsdale Flight Standards District Office opened both engine cowls to gain access to the engines. According to their statement: " The left and right upper ignitor leads safety wire was removed and leads loosened at the ignitor attach points. The upper ignitors were removed, visually inspected and placed in appropriate bags and marked left and right." Subsequently, the ignitors were reinstalled at the direction of the Safety Board.

The main left engine fuel line from the firewall to fuel pump was loosened at the fuel pump attach and fuel was observed flowing from this line. The main right engine fuel line from the firewall was loosened at the firewall (for accessibility to the fuel pump). Fuel was observed flowing from the fitting on the firewall, with residual fuel in the line. Both left and right engine lines were loosely reinstalled.

The right engine fuel line was loosened at the engine electro/mechanical fuel shutoff valve downstream of the valve. No fuel was observed in the line. The line was left loosened. The right engine combustion chamber aft upper plug safety wire was removed.

Continuity for the power and speed levers was established at both engines control linkage assembly. Levers were returned to their original positions.

On March 6, 1997, the right engine was installed into a test cell at the Allied Signal facility in Phoenix, Arizona. The engine was test run to a test plan. After the first test run the engine was shut down. A used fuel filter that was removed at the accident site was installed into the fuel system during the engine test cell run. The used filter had no effect on the fuel flow to the engine during the second test run. The fuel shutoff valve was manually operated.

The left engine was impact damaged and not runable. The left engine's compressor and transition duct was internally boroscoped for damage and no operational damage was found during that examination.

Wreckage and impact information

The accident site examination revealed that the aircraft first contacted the ground with it's tail fin. The next visible signs of contact were the right main gear dual wheels and the left dual wheels. The extended landing gears separated, leaving gear doors and belly antennas along the wreckage path, which measured to be 285 feet long on a magnetic heading of 355 degrees.

The left engine propeller was found separated from the engine drive shaft flange. Examination of the propeller blades revealed some rotation at the time of ground contact. The spinner dome revealed an impact to the dome without signs of rotation.

Examination of the right propeller revealed no rotational signatures at ground contact, with two propeller blades bent aft.

Both main fuel tanks were found ruptured. Fuel evidence was found in the soil in the area of both wings and forward of the aircraft towards lower ground. The left firewall shutoff was found in the closed position; the right firewall shutoff valve was found in the open position. According to both pilots, there was 500 pounds of fuel per side remaining at the time of the approach into Bullhead City. Subsequent field calculations indicated 965 pounds remaining between both fuel tanks.

According to the operator the aircr

Aircraft

Registration
N165SW
Reported as
Fairchild SA227-AC
Category
Airplane
Serial number
AC-514
Airframe hours
25,111
Engine
Garrett TPE331-11U612, 1,100 horsepower, turbo prop
Damage
Destroyed
Flight
Part 135
Operator
Fng Aviation Inc, doing business as Skylink Charter
Registered owner
First Security Bank Utah Na Tr
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · January 3, 1997 · 20 hours before
Departed
LGB · Long Beach, CA
Destination
GCN · Grand Canyon, AZ
Flight plan
VFR/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
33
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
3,200 total · 300 in this make and model · 3,000 as pilot in command · 50 in the last 90 days · 10 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 7 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
50 °F
Observed at
KIF, 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.

Other investigations on N165SW · 1

Matched to the same aircraft by N-number and date.