air tahoma flight 185 convair 580 august 13 2004 covington kentucky n.
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Air Tahoma Flight 185 Convair 580 August 13, 2004 Covington, Kentucky. Non-Contributing Factors. No preexisting failures No evidence of fatigue Sufficient fuel on board. Accident Summary. Captain was distracted Weight and balance during flight Crossfeed operations

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Presentation Transcript
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 & cockpit placard

Fuel transfer from tank to tank isprohibited. 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 opportunities1
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 opportunities2
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
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

NTSB Staff
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