N165SW

HISTORY OF FLIGHT

On January 5, 1997, at 1243 hours mountain standard time, a Fairchild SA-227-AC, N165SW, serial no. AC-514, collided with terrain about 1.5 miles south of the Bullhead City, Arizona, airport following the near simultaneous flame out of both engines. The aircraft was operated by FNG Aviation, d.b.a. Skylink Charters of Santa Monica, California, as an on-demand air taxi flight under 14 CFR Part 135. The aircraft was destroyed in the ground collision sequence. The two pilots sustained minor injuries, and the 19 passengers were uninjured. Visual meteorological conditions prevailed at the departure point, and a VFR/IFR flight plan was filed.

The flight originated at Long Beach, California, at 0900 Pacific standard time as a non-stop flight to the Grand Canyon in Arizona. Instrument meteorological conditions prevailed at the Grand Canyon and the aircraft was cleared for a localizer instrument approach. The weather was below landing minimums and the pilot executed a missed approach. He then diverted to the company designated alternate airport at Bullhead City.

Both pilots reported they had experienced minimal icing at the Grand Canyon. The captain estimated about 1/8 inch had accumulated on the wings. The pilots stated that they exercised the deice boots one time. They also stated that they never used override ignition during the flight.

On January 6, 1997, the cockpit voice recorder (CVR), the only recorder onboard, was sent to the Safety Board's Laboratory for a readout. The tape contained 32 minutes of recording, starting about the time the aircraft was leaving the Grand Canyon for Bullhead City.

According to the CVR, at 6.5 miles out on final approach for runway 34, the aircraft was at 150 knots. At 1239:54, the captain called for full flaps and requested the first officer advise the tower that they were slowing to 130 knots for traffic.

At 1240:41, both engines started spooling down. At 1240:44, the captain said "dual failure. Feather, feather 'em, feather 'em." The first officer asked which engine? The captain stated "both of 'em." At 1241:48, the first officer stated "no attempts on re-starts." The captain responded "yes, go through it. Go through the check list quick." At 1243, the CVR recording ended.

According to a postaccident interview of the first officer; there were no mechanical malfunctions encountered during the entire flight. No annunciator lights were illuminated, and all systems were (ok).

A review of the Fairchild SA-227 FAA Approved Flight Manual (AFM) revealed that there are no procedures in the AFM that addresses a dual engine flameout.

PERSONNEL INFORMATION

CAPTAIN

The captain was hired on September 7, 1994, and at the time of the accident he reported a total flight time of 3,200 hours with 300 hours in type. The captain was FAA type rated in the SA-227 aircraft. Examination of the pilot training records reveal that on September 17, 1993, he attended a 19.5 hour Allied Signal Aerospace TPE331 Engine Pilot Familiarization Course. On May 18, 1996, the pilot was awarded a certificate after 45 hours of ground school training on the Metro III / SA227 aircraft. On June 9,1996, the captain successfully passed an Airman Competency/Proficiency Check Ride for Part 135.293, 135.297, and 135.299.

FIRST OFFICER

The first officer was hired on September 6, 1996, and at the time of the accident he reported a total flight time of 640 hours with 56 hours in the make and model. The records indicate that since the hire date he has received about 93 hours of training recommended in the FNG Aviation training manual on the Fairchild SA-226 and SA-227 aircraft and the general FAA approved operations manual of procedures. The records also indicate that he successfully passed two Airman Competency/Proficiency Check Rides for second-in-command Part 135.293 in the SA-226/SA-227 aircraft by the operators chief pilot, both in September 1996.

AIRCRAFT INFORMATION

The aircraft was being maintained on a continuous airworthiness program. The last phase inspection occurred on December 27, 1996, 20.7 hours prior to the accident. The total time on the airframe was listed as 25,110 hours. According to the pilots, there were no unresolved maintenance items.

At the accident site the Hobbs meter indicated 4,023.8 hours, and the fuel used meter indicated 1,385 pounds.

ENGINE EXAMINATIONS

Accident site engine examinations were conducted by the Safety Board with engine manufacturer representatives prior to removal of the wreckage to a secure storage area.

Prior to the beginning of the formal examination, the FAA participants from the Scottsdale Flight Standards District Office opened both engine cowls to gain access to the engines. According to their statement: " The left and right upper ignitor leads safety wire was removed and leads loosened at the ignitor attach points. The upper ignitors were removed, visually inspected and placed in appropriate bags and marked left and right." Subsequently, the ignitors were reinstalled at the direction of the Safety Board.

The main left engine fuel line from the firewall to fuel pump was loosened at the fuel pump attach and fuel was observed flowing from this line. The main right engine fuel line from the firewall was loosened at the firewall (for accessibility to the fuel pump). Fuel was observed flowing from the fitting on the firewall, with residual fuel in the line. Both left and right engine lines were loosely reinstalled.

The right engine fuel line was loosened at the engine electro/mechanical fuel shutoff valve downstream of the valve. No fuel was observed in the line. The line was left loosened. The right engine combustion chamber aft upper plug safety wire was removed.

Continuity for the power and speed levers was established at both engines control linkage assembly. Levers were returned to their original positions.

On March 6, 1997, the right engine was installed into a test cell at the Allied Signal facility in Phoenix, Arizona. The engine was test run to a test plan. After the first test run the engine was shut down. A used fuel filter that was removed at the accident site was installed into the fuel system during the engine test cell run. The used filter had no effect on the fuel flow to the engine during the second test run. The fuel shutoff valve was manually operated.

The left engine was impact damaged and not runable. The left engine's compressor and transition duct was internally boroscoped for damage and no operational damage was found during that examination.

WRECKAGE AND IMPACT INFORMATION

The accident site examination revealed that the aircraft first contacted the ground with it's tail fin. The next visible signs of contact were the right main gear dual wheels and the left dual wheels. The extended landing gears separated, leaving gear doors and belly antennas along the wreckage path, which measured to be 285 feet long on a magnetic heading of 355 degrees.

The left engine propeller was found separated from the engine drive shaft flange. Examination of the propeller blades revealed some rotation at the time of ground contact. The spinner dome revealed an impact to the dome without signs of rotation.

Examination of the right propeller revealed no rotational signatures at ground contact, with two propeller blades bent aft.

Both main fuel tanks were found ruptured. Fuel evidence was found in the soil in the area of both wings and forward of the aircraft towards lower ground. The left firewall shutoff was found in the closed position; the right firewall shutoff valve was found in the open position. According to both pilots, there was 500 pounds of fuel per side remaining at the time of the approach into Bullhead City. Subsequent field calculations indicated 965 pounds remaining between both fuel tanks.

According to the operator the aircraft departed Long Beach with 2,345 pounds of fuel, which is the normal load for the flight to the Grand Canyon and back to Long Beach with reserve.

TESTING AND RESEARCH

On April 30, 1985, the engine manufacturer Garrett Turbine Engine Company, issued Operating Information No. 01 331-11. The application was for all TPE331 engines, except TPE331-14. The information was to emphasize proper use of inlet anti-ice and to provide additional information on the supplemental use of engine ignition in icing conditions.

On November 15, 1994, the engine manufacturer Garrett/ Allied Signal Aerospace, issued a Pilot Advisory Letter "Operating Information" No. 331-04R1, for operations in icing conditions. This letter provides additional emphasis on the coincident use of engine ignition when operating in icing conditions. The letter states: " regardless of whether operating in textbook icing conditions, engine ignition should be "ON" or 'ARMED/AUTO (if equipped with AUTO)' any time ice is observed to be collecting on the propeller spinners the wing leading edges or unheated inboard propeller blade cuff areas. Remember, ice accumulation can, under some conditions, be difficult to see." This aircraft does not have an ignition "ON" position, however, it does have an OVERRIDE position which provides continuous ignition.

On November 1, 1993, November 6, 1995, and April 25, 1997, Allied Signal (formerly Garrett) issued Operating Information Letter 01-331-11 R1 through R3. PURPOSE: To emphasize proper use of engine inlet anti-ice and provide additional information on the use of engine ignition in icing conditions. This operating information is only sent out to operators that are on the Allied Signal mailing list.

The issuance of the operating information followed several reported incidents where TPE331 engines flamed-out during or following operation in icing conditions. The operating information stated that in some cases, flameouts have occurred after the flights entered clear weather conditions during the descent into warmer ai...