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Executive Airlines N16EJ

Accident Case Study

 


 

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Photo: Accident site illustrating lack of fire damage to surrounding area, from NTSB AAB DCA00MA052, photo 2.

Accident Report

  • Date: May 31, 2000
  • Time: 11:28 EDT
  • Type: British Aerospace Jetstream 3101
  • Operator: East Coast Aviation Services (doing business as Executive Airlines)
  • Registration: N16EJ
  • Fatalities: 2 of 2 crew, 17 of 17 passengers
  • Aircraft Fate: Destroyed
  • Phase: Approach
  • Airport: (Departure) Atlantic City International Airport, KACY
  • Airport: (Arrival) Wilkes-Barre/Scranton International Airport, KAVP

Narrative

[NTSB AAB DCA00MA052, pages 1 - 4.]

  • Fuel facility records at ACY indicated that no additional fuel was added.
  • According to ATC transcripts, the pilots first contacted AVP approach controllers at 1057 and were vectored for an instrument landing system approach to runway 4. The flight was cleared for approach at 1102:07, and the approach controller advised the pilots that they were 5 nautical miles (nm) from Crystal Lake, which is the initial approach fix (IAF) for the ILS approach to runway 4. The pilots were told to maintain 4,000 feet until established on the localizer. At 1104:16, the approach controller advised that a previous landing aircraft picked up the airport at minimums [decision altitude]. The pilots were instructed to contact the AVP local (tower) controller at 1105:09, which they did 3 seconds later. The airplane then descended to about 2,200 feet, flew level at 2,200 feet for about 20 seconds, and began to climb again about 2.2 nm from the runway threshold when a missed approach was executed.
  • At 1107:26 the captain reported executing the missed approach but provided no explanation to air traffic controllers. The tower controller informed the North Radar approach controllers of the missed approach and then instructed the accident flight crew to fly runway heading, climb to 4,000 feet, and contact approach control on frequency 124.5 (the procedure published on the approach chart). The pilots reestablished contact with the approach controllers at 1108:04 as they climbed through 3,500 feet to 4,000 feet and requested another ILS approach to runway 4. The flight was vectored for another ILS approach, and at 1110:07 the approach controller advised the pilots of traffic 2 nm miles away at 5,000 feet. The captain responded that they were in the clouds. At 1014:38, the controller directed the pilots to reduce speed to follow a Cessna 172 on approach to the airport, and the captain responded, "ok we're slowing." The flight was cleared for a second approach at 1120:45 and advised to maintain 4,000 feet until the airplane was established on the localizer.
  • At 1123:49 the captain transmitted, "for uh one six echo juliet we'd like to declare an emergency." At 1123:53, the approach controller asked the nature of the problem, and the captain responded, "engine failure." The approach controller acknowledged the information, informed the pilots that the airplane appeared to be south of the localizer (off course to the right), and asked if they wanted a vector back to the localizer course. The flight crew accepted, and at 1124:10 the controller directed a left turn to heading 010, which the captain acknowledged.
  • It appears the airplane was turning itself off course because of the asymmetric thrust, though it should have been perfectly capable of continuing the approach to landing had the pilots corrected the yaw with rudder.

  • At 1124:33, the controller asked for verification that the airplane was turning left. The captain responded, "we're trying six echo juliet." At 1124:38, the controller asked if a right turn would be better. The captain asked the controller to "stand by." At 1125:07, the controller advised the pilots that the minimum vectoring altitude (MVA) in the area was 3,300 feet. At 1125:12, the captain transmitted, "standby for six echo juliet tell them we lost both engines for six echo juliet." At that time, ATC radar data indicated that the airplane was descending through 3,000 feet.
  • The controller immediately issued the weather conditions in the vicinity of the airport and informed the flight crew about the location of nearby highways. At 1126:17, the captain asked, "how's the altitude look for where we're at." The controller responded that he was not showing an altitude readout from the airplane and issued the visibility (2.5 miles) and altimeter setting. At 1126:43, the captain transmitted, "just give us a vector back to the airport please." The controller cleared the accident flight to fly heading 340, advised the flight crew that radar contact was lost, and asked the pilots to verify their altitude. The captain responded that they were "level at 2,000." At 1126:54, the controller again advised the flight crew of the 3,300-foot MVA and suggested a 330° heading to bring the airplane back to the localizer. At 1127:14 the controller asked, "do you have any engines," and the captain responded that they appeared to have gotten back "the left engine now." At 1127:23, the controller informed the pilots that he saw them on radar at 2,000 feet and that there was a ridge line between them and the airport. The captain responded, "that's us" and "we're at 2,000 feet over the trees." The controller instructed the pilots to fly a 360° heading and advised them of high antennas about 2 nm west of their position.
  • At 1127:46, the captain transmitted, "we're losing both engines." Two seconds later the controller advised that the Pennsylvania Turnpike was right below the airplane and instructed the flight crew to "let me know if you can get your engines back." There was no further radio contact with the accident airplane. The ATC supervisor initiated emergency notification procedures. A Pennsylvania State Police helicopter located the wreckage about 1236, and emergency rescue units arrived at the accident site about 1306. The accident occurred in daylight instrument meteorological conditions (IMC).

Analysis

[NTSB AAB DCA00MA052, pages 12 - 34.]

    The aircraft flew empty from Farmingdale (FRG) to Atlantic City (ACY). It was refueled at FRG but not ACY.

  • The FBO fueler at FRG stated that the accident flight crew was at the airplane when he arrived in his fuel truck. He stated that one pilot, whom he described as smaller than the other, requested that the fuel tanks be topped off. The fueler stated that the larger pilot later requested 60 gallons of fuel, 30 gallons in each tank. He stated that he could not see the refueling meter while he was refueling and asked the larger pilot to monitor the meter. The fueler stated that, at one point, he stopped fueling and asked the pilot to tell him the meter indication and stated that he was told 4.5 (or 45 gallons). He stated that he asked the pilot if he wanted him to put 15 gallons in the other tank for a total of 60 gallons. The fueler stated that the larger pilot told him to put 45 gallons in the other tank for a total of 90 gallons. Fuel truck and billing records confirmed the purchase of 90 gallons of fuel. The pilots did not receive a copy of the fuel receipt because Executive Airlines had a fueling contract with the FBO. The fueler stated that he "did not observe either pilot check the fuel drip sticks, climb up the fueler's ladder to check the fuel, or walk around the airplane."
  • The accident first officer's fiancée, who was a passenger on the first leg of the accident flight from FRG to ACY, stated that the first officer told her that one fuel gauge read 300 pounds and that the other read 900 pounds and that she subsequently saw these gauge readings herself. She stated that the 300-pound indication was "the right side." She stated that the first officer remarked, "I don't even know how to tell how much fuel we have on board." She stated that the pilots did not remain outside the airplane during fueling because it was raining.
  • Statements from the carrier's owner and the first officer's fiancée and information from the weight and balance form completed by the accident crew suggest that the flight crew planned to add a total of 180 gallons to the airplane. If the flight crew intended to load 180 gallons (about 1,200 pounds), it was common industry and company practice to ask for 90 gallons on each side. However, based on the evidence, it appears that a lack of clear communication between the pilots and the fueler resulted in only 90 gallons (about 600 pounds) of fuel being added, a total amount confirmed by the fuel order receipt. Further, it is likely that the flight crew did not confirm the amount of fuel loaded before departure because flight crews do not see the fuel receipts after fueling and because the pilots were not outside the airplane monitoring the fuel loading.
  • The accident flight crew completed a load manifest that stated that the airplane was loaded with 2,400 pounds of fuel when it departed from FRG, and it is probable that the accident flight crew planned to depart from FRG with 2,400 pounds. Based on the airplane's performance, 2,400 pounds of fuel would have been sufficient fuel to fly the two flights without adding fuel during the stop at ACY. This would have allowed a takeoff from ACY that was within normal weight and balance limits for the airplane with 17 passengers on board. There was no evidence that the flight crew asked for additional fuel to be added during the stop at ACY.
  • However, based on the Safety Board's calculations, it appears that the accident airplane departed FRG with about 1,600 pounds of fuel on board, which is 800 pounds less than listed on the load manifest. Therefore, the Safety Board concludes that the accident airplane departed FRG with less fuel than the pilots thought they had on board.
  • The left engine low pressure (LP) fuel valve actuator was found separated from its valve and the right engine LP fuel valve was found intact. The valve position indicators on both valves were in the open position, consistent with the observed valve positions. The left and right hydraulic LP cocks were also found in the open position. The crossfeed valve was found in a clump of melted aluminum. The melted aluminum was removed and the crossfeed valve position indicator was found in the closed position, consistent with the observed valve position. The LP fuel cock switches in the cockpit were consumed by the postimpact fire.
  • The No. 1 (left) engine was found partially attached to the left wing. There was no visible sign of any uncontained engine failure (that is, engine parts exiting the casing) or fire damage in the engine.
  • The tip of blade No. 1 was curled, and the blade had an "S" shape, bent in the direction opposite rotation.
  • A teardown examination of the No.1 (left) engine found rotational scoring and metal spray indicating that the engine was developing power at impact. An examination of the No. 2 (right) engine, which found static imprints and no evidence of rotational scoring or metal spray, determined that the engine was not running at impact.
  • The airplane should have been easily controlled with an engine shutdown and should have been able to maintain level flight or even climb under these conditions, provided it was flown in coordinated flight.

  • The No. 2 (right) engine was found partially attached to the right wing. The propeller assembly was attached to the engine. There were no visible signs of any uncontainments. The No. 2 engine's propeller assembly had three blades intact and one blade fractured. Blade No. 2 was fractured 34 inches outboard from the hub. Blade No. 3 was bent in the direction of rotation. Blade No. 3 had a sharp bend, slightly less than 90°, located 17 inches outboard from the hub. Blades No. 1 and No. 4 were straight.
  • ATC approach radar data indicated that the accident airplane deviated 55° in a right turn away from the localizer course during the second approach to AVP. Shortly after this deviation, the pilots informed the AVP controller that they were declaring an emergency because of engine failure. The deviation to the right was likely the result of asymmetrical thrust caused by stoppage of the right engine. Experiencing engine failure in IMC could cause pilots to fixate on instruments such as the attitude indicator and airspeed indicator and to allow the course heading to wander. However, during simulator tests, Safety Board investigators had minimal difficulty maintaining heading and controllability after a simulated right engine failure during approach to a landing.

Probable Cause

[NTSB AAB DCA00MA052, page 34.] The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's failure to ensure an adequate fuel supply for the flight, which led to the stoppage of the right engine due to fuel exhaustion and the intermittent stoppage of the left engine due to fuel starvation. Contributing to the accident were the flight crew's failure to monitor the airplane's fuel state and the flight crew's failure to maintain directional control after the initial engine stoppage.

The aircraft crashed because the pilots lost directional control due to the engine failure, and because they were unable to maintain level flight with an engine failed. The engine failed because they failed to ensure they had adequate fuel on board.

See Also:

References

NTSB Aircraft Accident Brief, DCA00MA052, Executive Airlines Flight N16EJ, BAE Systems J-3101, N16EJ, May 21, 2000

Revision: 20150118
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