MIA96FA162

NTSB accident investigation · Embraer 120 · Orlando, FL · June 23, 1996

Accident · No injuriesField investigationFinal report
Date
June 23, 1996, 11:16 local (15:16 UTC)
Place
Orlando, FL
Injuries
32 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N168CAEmbraer 120
Weather
Visual (VMC) · Day
Status
Completed · report April 3, 1997
Report
Approved by Office Director
FAA report
19960623019909A
Case key
37908

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

the aircraft manufacture's inadequate written procedures in the airplane flight manual/quick reference handbook, which resulted in a failure of the landing gear to extend and a wheels up emergency landing, due to hydraulic blockage in the landing gear solenoid valve. Factors relating to the accident were: the chafed and ruptured hydraulic line and the subsequent hydraulic leak, which resulted in loss of hydraulic pressure and an inoperative normal landing gear extension system.

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/malfunctionDescent
Hydraulic system,line - chafedFactor
Hydraulic system,line - rupturedFactor
Fluid,hydraulic - leakFactor
Landing gear,normal retraction/extension assembly - inoperative
Wheels up landingEmergency landing
Aircraft manuals,procedure information - inadequateCause
Procedure inadequateManufacturerCause
Hydraulic system - blocked(total)
Gear extension - not attained

Analysis

The airplane experienced a total loss of hydraulic pressure and hydraulic fluid while on descent to the destination airport. The flight crew conducted emergency procedures (hydraulic failure/landing gear failure) in accordance with the airplane flight manual (AFM)/quick reference handbook (QRH) with negative results. Subsequently, a wheels up landing was made. Examination of the airplane revealed a rupture of the No. 1 engine-driven hydraulic pump pressure hose. Review of the AFM and QRH emergency procedures revealed the manual did not discriminate between hydraulic or electrical failures. The procedures listed in the maintenance manual for lowering the landing gear by the free-fall mechanism were different from the AFM/QRH. Functional test of the landing gear system, using the AFM/QRH, resulted in the landing gear failing to extend due to hydraulic blockage in the landing gear solenoid valve. Functional test of the landing gear system, using the free-fall procedure contained in the maintenance manual, resulted in the extension of the landing gear.

Factual narrative

History of flight

On June 23, 1996, about 1116 eastern daylight time, an Embraer EMB120, N168CA, registered to COMAIR Aircraft Inc., flight number 3599, operating as a 14 CFR Part 135 scheduled domestic passenger flight, experienced a landing gear failure on arrival at the Orlando International Airport, Orlando, Florida. The flightcrew completed emergency procedures with negative results, and an emergency landing was made. Visual meteorological conditions prevailed, and an IFR flight plan was filed. The airplane sustained substantial damage. The airline transport pilot-in-command, first officer, 1 flight attendant, and 29 passengers were not injured. The flight originated from Nassau, Bahamas, 2 hours 13 minutes before the accident.

The pilot-in-command stated on descent into the Orlando area the hydraulic master caution warning light illuminated, followed by the low level advisory light on the green hydraulic system. He instructed the first officer to review the loss of hydraulic pressure procedure in the quick reference handbook. The hydraulic master caution warning light illuminated again, followed by the low pressure advisory light on the green hydraulic system. The fluid level was pointing to the yellow, the hydraulic pressure was decreasing, and the light for the green system was flashing on and off. The flightcrew concluded that the green hydraulic system was empty and the green electric hydraulic pump was turned off. They discussed what systems would be lost in the event of a total failure of the green hydraulic system, and decided to lower the flaps and landing gear. The flaps were extended to 15 degrees; however the landing gear would not extend. They informed ATC of situation, and were placed in a box pattern east of Orlando International Airport. They performed the abnormal emergency landing gear instructions in the checklist and contacted the COMAIR maintenance facility for further instructions. Repeated attempts to lower the landing gear were unsuccessful, and a gear up landing was performed.

Personnel information

All pertinent aviation regulations, 14 CFR Part 135, airman competency and proficiency checks, had been recorded as conducted. The pilot stated, he had never conducted an abnormal landing gear extension in the EMB120, and he could not remember the last time he performed the procedure in the flight simulator. COMAIR training records reflects emergency training and emergency drills. The training records do not indicate what type of emergency training or drills were conducted. (For additional first pilot information, see page 3 of this report.)

All pertinent aviation regulations, 14 CFR Part 135, airman competency and proficiency checks had been recorded as conducted. The first officer stated he has never conducted an abnormal landing gear extension in the EMB120; however, he conducted one abnormal landing gear extension during his last simulator period in November 1995. COMAIR training records reflect emergency training and emergency training drills were conducted on November 11, 1995. (For additional second pilot information, see NTSB Form 6120.4 Supplement E.)

All pertinent aviation regulations, 14 CFR Part 135 and Part 121, competency and proficiency checks had been recorded as conducted. (For additional flight attendant information, see NTSB Form 6120.4 Supplement U.)

Aircraft information

Aircraft information is contained on page 2 of this report.

Meteorological information

Visual meteorological conditions prevailed at the time of the accident. (For additional weather information, see page 3 of this report.)

Flight recorders

N168CA was equipped with a Fairchild model A100A cockpit voice recorder. The recorder was forwarded to the NTSB Laboratory for analysis. The cockpit voice recorder was recorded clearly and the entire tape was transcribed. (For additional information, see NTSB Cockpit Voice Recorder Factual Report.)

N168CA was equipped with a Fairchild model F1000 flight data recorder. The flight data recorder was forwarded to the NTSB Laboratory for analysis. A transcription was accomplished using normal recovery procedures, which converted the raw data to engineering units, and is presented in tabular and graphic form. (For additional information, see NTSB Flight Data Recorder Factual Report.)

Wreckage and impact information

COMAIR flight 3599, N168CA, was located just north of taxiway Juliet, on runway 36R at the Orlando International Airport, Orlando, Florida, on a heading of 351 degrees. Examination of the runway revealed N168CA touched down just north of taxiway Bravo, and slid 2,500 feet before the airplane came to a complete stop.

Examination of the airplane before recovery revealed the nose gear doors were partially open but were not releasing, and the nose gear was off the uplock position. Both main landing gear doors were observed in the uplock position. The airplane was lifted by airbags and placed on jacks. Normal attempts to lower the landing gear failed. The hydraulic manual selector valve was placed in the maintenance position. The nose gear doors opened and the nose gear extended to the full down position. The main landing gear doors sustained impact damage and had to be pried open before the landing gear could be lowered by activating the free fall mechanism. The airplane was lowered to the ground and towed to the COMAIR maintenance facility.

Examination of the airframe, flight controls, and engine assemblies revealed no evidence of a precrash mechanical failure or malfunction. Continuity of the flight control system was confirmed for pitch, roll, and yaw.

Examination of the green and blue hydraulic reservoirs revealed the green reservoir was empty, and the blue reservoir contained hydraulic fluid. Hydraulic fluid was added to the green reservoir. The engine-driven hydraulic pump pressure hose on the No. 1 engine was pressurized to over 2200 psi using a hydraulic cart. A rupture measuring 0.5 inch of diameter on the surface and 0.25 inch of diameter of metal braid was present in the vicinity of the forward left hand nacelle cowling hold-open rod. This was a result of chaffing/friction against the clip that secures the cowling support rod and stowaway clamp.

Functional ground test of the abnormal landing gear extension procedure were performed. The first and second attempt were successful. The third test and all subsequent tests failed due to a hydraulic blockage of the landing gear solenoid valve. Additional tests revealed that if the checklist procedures were not followed in sequence, the abnormal landing gear extension procedure would fail. Electrical troubleshooting of the landing gear wiring, electric override switch, wiring to the landing gear door electrovalve, and the landing gear electrovalve revealed no deficiencies that could be attributed to the failure of the landing gear to extend. (For additional information, see Embraer NTSB Airplane Systems Group-Preliminary Factual Report, and FAA Accident Investigation Report dated June 23, 1996.)

The landing gear solenoid valve, hydraulic reservoir unit, and hydraulic pump were forwarded through the FAA Manufacturing Inspection District Office to the manufacturer for further analysis. The free-fall emergency selector valve, and the landing gear control box were examined at an authorized repair station. No deficiencies were noted that could be attributed to the failure of the landing gear to extend. (For additional information, see Test Report dated July 26, 1996, and August 27, 1996.)

Medical and pathological information

Toxicology testing of specimens obtained on June 23, 1996, from the pilot-in-command, first officer, and flight attendant, were performed by Phaneuf Associates Inc., Washington D.C. These tests were negative for marijuana, cocaine, phencyclidine, amphetamines, and opiates. Test for alcohol were negative for the pilot-in-command and first

Aircraft

Registration
N168CA
Reported as
Embraer 120
Category
Airplane
Serial number
168
Airframe hours
16,775
Engine
P&W PW118, 1,800 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Registered owner
Comair
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · June 22, 1996 · 3 hours before
Departed
NAS · Nassau, OF
Destination
MCO
Flight plan
IFR
Airport
MCO · Orlando International, runway 36R, 10,953 × 200 ft, asphalt

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
41
Certificate
Airline transport
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
8,300 total · 3,600 in this make and model · 6,950 as pilot in command · 195 in the last 90 days · 40 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 7 knots
Visibility
8 statute miles
Lowest ceiling
25,000 ft overcast
Temperature
90 °F, dew point 79 °F
Altimeter
30.00 inHg
Observed at
MCO

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.