Presentation Transcript
Air Tahoma Flight 185Convair 580August 13, 2004Covington, Kentucky: Air Tahoma Flight 185 Convair 580 August 13, 2004 Covington, Kentucky
Non-Contributing Factors: Non-Contributing Factors No preexisting failures
No evidence of fatigue
Sufficient fuel on board
Accident Summary: Accident Summary Captain was distracted
Weight and balance during flight
Crossfeed operations
Proper procedures not followed
Fuel transferred between tanks
Flight crew missed opportunities
Dual engine flameout
Main Investigative Areas: Main Investigative Areas Captain’s weight and balance calculations
Fuel crossfeed operation
Monitoring fuel quantity
Dual engine flameout
Weight and Balance: Weight and Balance No load manifest left at Memphis
Weight and balance computer inoperative
Paperwork – outside limits
Used 'general experience'
Distraction: Distraction Captain completing paperwork in flight
50 minutes after takeoff
started crossfeed operations
Captain did not follow procedures
Convair 580 Limitations: Convair 580 Limitations Fuel transfer prohibited
AFM andamp; cockpit placard
Fuel transfer from tank to tank is prohibited. When operating with the crossfeed system, turn off fuel valve for tank not being used.
No history of valve failures
Missed Opportunities: Missed Opportunities Airplane handling characteristics
Over the last 9 minutes
First officer
'yoke feels funny'
'feels like I need a lot of force'
'what in the world is going on with this plane'
Missed Opportunities: Missed Opportunities Captain did not
Check fuel quantity
Initiate troubleshooting
Assess the handling qualities
Captain
'we’ll do a full control check on the ground'
Missed Opportunities: Missed Opportunities Captain
Started in-range checklist at 3,200 feet
Found open crossfeed
30 seconds before dual engine flameout
Air Tahoma Procedures
Start in-range checklist at 12,000 feet
Significant Findings: Significant Findings Captain was distracted during flight
Improper fuel crossfeed
Flight crew missed opportunities
Different fuel pump pressures
NTSB Staff: NTSB Staff Tom Jacky
David Tew
Malcolm Brenner
Clint Crookshanks
Anna Cushman
Greg Smith
Pierre Scarfo Abdullah Kakar
Kristen Sears
Paul Sledzik
Brian Fiffick
Paul Schlamm
Christy Spangler
Gina John
Sonia Louallen
Parties and Accredited Rep: Parties and Accredited Rep PARTIES
Federal Aviation Administration
Air Tahoma
Rolls-Royce
ACCREDITED REPRESENTATIVE
Transportation Safety Board of Canada
Kelowna Flightcraft Ltd.
Office of Aviation Safety Workload: Office of Aviation Safety Workload 8 major investigations
5 major reports
385 regional investigation launches
21 foreign investigation launches
88 safety recommendations
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