NTSB probable cause on AT

[Rogue5]

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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: May 2, 2006
SB-06-27

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FUEL STARVATION CITED AS CAUSE OF CARGO AIRPLANE CRASH

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Washington, DC - The National Transportation Safety Board
today determined that the probable cause of the crash of an
AT cargo airplane, on August 13, 2004, was "fuel
starvation resulting from the captain's decision not to
follow approved fuel crossfeed procedures."

Contributing to the accident were "the captain's inadequate
preflight planning, his subsequent distraction during the
flight, and his late initiation of the in-range checklist."
Further contributing to the accident, the Board said, was
"the flight crew's failure to monitor the fuel gauges and to
recognize that the airplane's changing handling
characteristics were caused by fuel imbalance."

"Here again we see the tragedy that can result when time-
tested procedures are not respected," said NTSB Acting
Chairman Mark V. Rosenker. "The accident also points up the
severe consequences that can follow when the operator of an
aircraft, or any other vehicle, becomes distracted."

The accident airplane, a Convair 580, was operating as a DHL
Express cargo flight from Memphis TN, when it crashed on
approach to landing at Cincinnati/Northern Kentucky
International Airport, in Covington KY. The first officer
was killed and the captain was injured. The airplane was
destroyed by crash impact forces.

Examination of the wreckage revealed no evidence of any pre-
crash problems with the airplane's engines, systems or
structures. There were no indications that the airplane's
cargo had shifted during the flight. Investigators also
determined that there was sufficient fuel on board for the
flight from Memphis to Covington.

Cockpit voice recorder information indicated that the
captain began fuel crossfeed operations about 50 minutes
into the flight, and that he allowed it to continue
unmonitored for almost 30 minutes. Post-accident
examination of the wreckage revealed that, contrary to
approved procedures, the fuel tank shutoff valve had been
left open during the crossfeed operations, which allowed
fuel transfer from the left tank to the right tank.

The Board concluded that, during the airplane's descent to
landing, the fuel in the left tank, which was providing fuel
to both engines, was exhausted because both engine-driven
fuel pumps drew air from the left tank into the fuel system
instead of fuel from the right tank, which led to a dual
engine flameout caused by fuel starvation.

Consequently, the Board recommended that the FAA issue a
flight standards information bulletin to familiarize Convair
580 operators with the circumstances of the AT
accident, including the importance of closing the fuel tank
shutoff valve for the tank not being used during crossfeed
operations. The Board further recommended that Convair 580
operators be required to use the same output pressure
settings on their left and right fuel pumps.

The Board, noting that additional details about the flight
crew's actions after the loss of engine power would have
aided the investigation, reiterated a previous
recommendation to the FAA (A-99-16), which called for
retrofitting airplanes with independently powered cockpit
voice recorders.

The texts of these recommendations and a synopsis of the
report can be found on the NTSB web site at www.ntsb.gov.
The complete report will be released at a later date.

##


NTSB Media Contact: Paul Schlamm (202) 314-6100


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[Rogue5]

Just to clarify, all references to

A
i
r

T
a
h
o
m
a

in the title and the text of this report were automatically edited out and changed to "AT" by the computer censor...

Can the website operator please grow up a little and start acting like an adult? This is a safety issue!

 

[belchfire]

Bummer on the NTSB finding. Other than that I have
to disagree with blatent abuse of censorship rules
in this case. This is a public forum, this particular
area being about Cargo operations, under
the more general heading "interview board".

I personally refrained from sending the aforementioned
alleged air carrier based on things mentioned here and
other areas. Research tools in aviation are important!

That could have been me in the right seat...except
that I have a family and the aforementioned alleged
air carrier's pay scale was too substandard and I never
would have taken a class...(turns out even I have
standards)!

I have read and heard in person so many safety related issues
and ligitimate complaints about the aforementioned and aleged
air carrier that censorship of the aforementioned alleged air
carrier's name could probably be considered violation of
public service clauses in the FCC's rule book.

I had one of the aforementioned air carrier's happy ex
employees as a FO in a previous job at another place
that deserves dishonorable mention (pm me for that
alleged airline's name) and he verified many of the
things that I had read and added his own tales of
horror.

If the names of the bad guys are censored, are the
censors liable for withholding information that gets
someone killed?

Chew on that for a while, all wise one(s)!!!

My condolences to the FO's survivors...

 

[AngelKing]

I have never flown for "AT", but have met some of the guys there when they took over our runs out of Miami. I have also heard all of the horror stories. They seem to be doing a good job in Miami. One of those runs is about 7 hours a day, 5 days a week. Also met the Captain of this accident flight. One of the nicest guys you could ever meet.

ak