N179GA – Dassault Aviation DA-20C – 2003-04-08 NTSB Accident Report

HISTORY OF FLIGHT

On April 8, 2003, at 1850 central daylight time (CDT), a Dassault DA-20C, Fan Jet Falcon, N179GA, operated by Grand Aire Express, Inc. as flight GAX179, was destroyed when it was ditched into the Mississippi River near St. Louis, Missouri. The airplane was approaching to land on runway 30R (9,003 feet by 150 feet), at the Lambert-St. Louis International Airport (STL), when it lost power to both engines. The 14 CFR Part 135 non-scheduled domestic cargo flight was operating on an instrument flight rules flight plan in instrument meteorological conditions at the time of the accident. The pilot and first officer received serious injuries. The airplane departed from the Del Rio International Airport, Del Rio, Texas, about 1630.

The airplane received vectors from air traffic control (ATC) for the instrument landing system (ILS) 30R approach to STL. During the first approach, the STL tower controller initially cleared the airplane to land on runway 30R. Later, the airplane was instructed to climb to 3,000 feet and to contact departure control. The airplane was then vectored for a second approach to runway 30R. While being vectored for the second approach, the flight crew asked controllers several times how far they were to be vectored away from the airport. When the airplane was on a base leg for landing, the flight crew reported that they had a "fuel limitation." They were then immediately issued vectors and cleared for the ILS 30R approach. After being switched to the tower frequency, the flight crew declared an emergency. The crew reported to the tower controller that they lost power to both engines. The airplane was subsequently ditched into the Mississippi River.

In an interview after the accident, the pilot-in-command (PIC) stated that during the first approach to land, when they were inside the outer marker of the approach, ATC instructed them to climb to 5,000 feet and "fly the heading." He stated that they were then vectored for another approach. The PIC stated that during the second approach they asked ATC how far out they were going to be taken and ATC responded 20 miles. He said that they were again cleared for the approach, intercepted, and broke out of the overcast. He stated that they went about 1 1/2 miles after that when the engines failed. He stated that during the second approach they questioned ATC several times as to how far away from the airport they were going to be taken on the approach. The PIC stated that they informed ATC of their fuel situation. He stated that they also asked ATC why they had been instructed to go-around on the first approach and that ATC did not give them an answer. The PIC stated that he had been assigned to the airplane since April 5, 2003, and that there were no problems with the airplane. In a later telephone interview, the pilot stated that the airplane had departed DRT with 6,200 pounds of fuel on board. The pilot subsequently provided a load manifest that indicated that the airplane was limited to 25,000 pounds takeoff weight due to runway and climb limitations. The manifest showed that the actual takeoff weight was 24,646 pounds.

In an interview after the accident, the second-in-command (SIC) stated that they had received vectors for the ILS 30R approach and that everything went "fine" until they were less than 7 miles from the airport. At that point, ATC instructed them to climb to 5,000 feet. He said that they were then vectored for another approach, during which time, they were sent 23 miles west of the airport, and then 17 miles east of the airport prior to being vectored back to the final approach for runway 30R. He stated that their fuel was critical and that the right engine stopped producing power about 15 miles from the airport. He said that the left engine stopped producing power about 30 seconds after the right engine stopped producing power. When questioned as to why he thought the engines stopped producing power, he said that they "ran out of fuel." He stated that when the right engine failed the fuel quantity indicator read zero, and when the left engine failed the fuel quantity indicator read 100 pounds. When asked if there were any problems with the airplane the SIC responded "No, the airplane was good." He also stated that after being instructed to climb to 5,000 feet after their first approach, he questioned the PIC about landing at the Spirit of St. Louis airport. The SIC said that the PIC elected to continue with the second approach to STL. The Spirit of St. Louis Airport is located about 14 nautical miles west-southwest of STL.

According to personnel statements made by FAA Air Traffic Control Specialists, the accident airplane was given missed approach instructions during its first instrument approach when adequate separation from another arriving aircraft could not be maintained.

PERSONNEL INFORMATION

The PIC held an airline transport pilot (ATP) certificate issued by the Federal Aviation Administration (FAA) on April 13, 2001. The ATP certificate listed ratings for multi-engine and single-engine airplanes. Single engine operations were limited to commercial privileges. He also held a certified flight instructor certificate with single-engine airplane, multi-engine airplane, and instrument airplane ratings. His first class medical certificate issued October 21, 2002 listed no limitations.

According to the operators records, the PIC had accumulated 3,221 total flight hours including 1,270 in the same make and model airplane as the accident airplane. Operator records show that the PIC was hired on April 11, 2000, and that he had satisfactorily completed upgrade training for the DA-20 on April 13, 2001. Training records indicate that the PIC's most recent Airman Competency/Proficiency Check, as required by 14 CFR Part 135.293, was satisfactorily completed on October 24, 2002.

The SIC held an ATP certificate issued by the FAA on April 24, 2001. The ATP certificate listed ratings for multi-engine and single-engine airplanes. His first class medical certificate issued October 21, 2002 listed the limitation that the pilot wear corrective lenses.

According to the operators records, the SIC had accumulated 5,758 total flight hours including 1,532 in the same make and model airplane as the accident airplane. Operator records show that the SIC was hired on October 26, 1999, and that he had satisfactorily completed upgrade training for the DA-20 on April 24, 2001. Training records indicate that the SIC's most recent Airman Competency/Proficiency Check, as required by 14 CFR Part 135.293, was satisfactorily completed on May 8, 2002.

AIRCRAFT INFORMATION

The airplane was Dassault DA-20, Serial number 100. The airplane was a two-engine turbofan powered low-wing airplane with an aluminum primary structure. Each engine was mounted in a pod attached to the fuselage side near the rear of the airplane. The accident airplane had been configured for cargo operations. According to maintenance records, the airplane had accumulated 15,899.3 hours total time in service as of the date of the accident. The airplane was part of an Approved Aircraft Inspection Program and was last inspected on March 17, 2003 at 15,866.1 total hours.

Two General Electric CF700-2D2 engines rated at 4,500 pounds of thrust each powered the airplane. The left engine, serial number 222J077, had accumulated 4,136.8 hours total time in service, 2,020.4 hours since overhaul, and 600.9 hours since inspection as of the date of the accident. The right engine, serial number 304-571, had accumulated 7,798.9 hours total time in service, 7,798.9 hours since overhaul, and 806.1 hours since inspection as of the date of the accident.

The airplane fuel system consisted of a wing and center wing fuel tank and a rear fuselage compartment tank per side. Fuel is transferred from the respective wing fuel tanks to the corresponding rear fuselage tank, and then to the respective engine. A crossfeed system is also provided. A magnetic ground fuel gauging system is contained in each inboard wing fuel tank for ground check of fuel quantity. Each wing and center wing tank combination has an electronic fuel gauging system consisting of 4 capacitance type sending units which are connected to a two-pointer gauge in the pilot compartment. One of the gauge pointers indicates the mass-quantity of fuel contained in the left wing/center wing fuel tank combination. Likewise, the other pointer indicates the mass-quantity of fuel contained in the right wing/center wing fuel tank combination. The rear fuselage mounted fuel tanks each contain a float type electronic fuel quantity sending unit. These sending units are connected to a two-pointer gauge to indicate the mass-quantity of fuel in the respective rear fuel tank. Right and left side low pressure transfer failure warning systems are installed to indicate the end of fuel transfer, transfer pump stoppage, or transfer pump failure. Each wing/center wing tank has a capacity of 571.3 gallons or 3,817.2 pounds of fuel, and each rear fuselage mounted tank can hold 108.5 gallons or 732.2 pounds of fuel.

METEOROLOGICAL INFORMATION

The recorded weather for STL at 1853 was: Wind- 020 degrees at 8 knots; Visibility- 2 statute miles; Weather condition- light rain and mist; Ceilings- 500 feet broken, 1200 feet overcast; Temperature- 4 degrees Celsius; Dewpoint- 4 degrees Celsius; Altimeter setting- 30.25 inches of mercury; Remarks- Surface visibility 2 1/2 statute miles, ceiling variable from 500 to 1000 feet, sea-level pressure 1024.7 millibars.

The Terminal Aerodrome Forecasts (TAF), for STL encompassing the accident time were obtained. At the time that the accident airplane's flight plan was filed, the TAF was:

Station Identifier: KSTL

Date and time of origin: April 8, 2003 at 1220 CDT

Valid period: Valid from 1300 CDT on April 8, 2003 until 1300 CDT on April 9, 2003

Forecast wind: 350 degrees at 11 knots

Forecast visibility: Greater than 6 statute miles

Forecast sky condition: Overcast clouds at 1,500 feet above ground level

The TAF listed that the forecast after 1000 CDT on April 9, 2003, the day after the accident, would be:

Forecast wind: 350 degrees at 11 knots

Forecast visibility: Greater then 6 statute miles

Forecast sky condition: Broken clouds at 3,500 feet above ground level

COMMUNICATIONS

On April 8, 2003, at 0918, a Direct User Access Terminal System (DUATS) abbreviated weather briefing request for GAX179 was received and processed by DynCorp Information Services LLC. At 1420, a flight plan was filed for GAX179 using DUATS. The listed route of flight was from Gainesville, Florida, to Del Rio, Texas.

On April 8, 2003, at 1324, an individual contacted the San Angelo Automated Flight Service Station and filed an IFR flight plan from Del Rio, Texas, to St. Louis International for GAX179. The caller requested flight level 330 and a direct route of flight. The pilot listed for the flight plan was the accident pilot. No alternate destination was listed. The caller requested no further services after the flight plan was filed. No record of a weather briefing for the flight from DRT to STL was found.

Transcripts for radio communications between STL air traffic controllers were obtained. At 1817:10, N179GA checked in on frequency with STL approach control. Between 1817:10 and 1832:24, STL approach vectored and subsequently cleared N179GA for the ILS runway 30R approach to STL before handing communication with the airplane off to STL tower controllers. At 1832:56, N179GA checked in on frequency with STL tower. Between 1832:56 and 1836:16, the airplane remained on the STL tower frequency. During this time, the STL tower controllers initially cleared N179GA to land and then subsequently instructed N179GA to climb to 3,000 feet and continue on the localizer. The airplane was subsequently handed off to STL departure control. At 1836:38, N179GA checked in on frequency with STL departure control. The transcripts contain no mention of a low fuel situation prior to 1836:38. The following excerpts are from transmissions between GAX179 and various control positions for the time period from 1836:38 to 1851:21. The abbreviations for the various entities making transmissions are as follows:

Transmitting entity Abbreviation

N179GA N179GA

STL Approach Control Arrival South Position STL-AS

STL Approach Control Departure South Position STL-DS

STL Tower Local Control North Position STL-NL

STL Tower Local Control Local Three Position STL-L3

1836:38 N179GA uh departure grand aire one seventy nine three thousand (unintelligible) maintaining heading

1836:43 STL-DS grand express one seventy nine saint louis departure radar contact climb and maintain five thousand

1836:49 N179GA uh maam five thousand you know what's uh what's up with uh why we are got a missed approach on that one seventy nine

1836:56 STL-DS grand express one seventy nine maintain five thousand i didn't understand your last sir

1837:01 N179GA uh we're climbing five thousand and i've a question that we were missed on that three zero right approach you know how far we're gonna go out this way

1837:09 STL-DS grand express one seventy nine turn left heading one eight zero

1837:13 N179GA one eight zero one seventy nine

1837:39 STL-DS grand express one seventy nine it be best to ask the tower once you get on the ground we don't know what happened

1837:46 N179GA okay and how long uh before we go on landing sir

1837:49 STL-DS about a twenty mile final

1838:24 STL-DS grand express one seventy nine turn left heading one two zero

1838:27 N179GA one two zero on heading one seventy nine

1839:04 STL-DS grand express one seventy nine maintain one niner zero knots for spacing

1839:07 N179GA one niner zero for spacing one seventy nine

1840:06 STL-DS grand express one seventy nine traffic one oclock two miles same direction a boeing seven five seven descending out of six thousand six hundred for six thousand

1840:15 N179GA one seventy nine uh we have in check

1840:26 STL-DS grand express one seventy nine contact saint louis approach one two six point five five

1840:30 N179GA twenty six fifty five

1840:42 N179GA good afternoon grand aire one seventy nine four thousand one two zero heading

1840:52 STL-AS grand aire one seventy nine saint louis roger maintain five thousand

1840:55 N179GA maintain five thousand uh one seventy nine

1843:16 N179GA departure grand expre grand aire one seventy nine how far are we going to stay on this heading sir

1843:22 STL-AS it'll be about ten more miles sir will that be all right

1843:25 N179GA uh we

1843:28 N179GA sir is it possible can we turn ah a little bit earlier than ten miles one seven nine

1843:33 STL-AS okay i'll turn you in sooner

1843:35 N179GA thank you

1844:15 STL-AS grand aire one seven nine reduce speed to one seven zero

1844:19 N179GA one seven zero one seventy one seven nine

1844:41 STL-AS grand aire one seven nine turn left heading zero three zero

1844:44 N179GA zero three zero one seven nine

1845:31 N179GA saint louis tower uh approach grand aire one seventy nine

1845:40 STL-AS grand aire one seventy nine say again

1845:42 N179GA yes sir how far are we gonna go on the zero two zero we might have uh little bit uh fuel uh limitation here

1845:49 STL-AS you're on a base turn sir to join final

1845:51 N179GA okay roger that one seventy nine

1846:17 STL-AS grand aire one seventy nine i may have to take you about a half a mile across final

1846:22 N179GA sir we have to make landing here we have uh limited fuel here

1846:27 STL-AS grand aire one seventy nine turn left a heading three three zero intercept three zero right localizer

1846:32 N179GA three three zero intercept the localizer one eight one seventy nine

1846:50 STL-AS grand aire one seventy nine six miles from exale cross exale at three thousand five hundred cleared i l s runway three zero right approach maintain one seven zero knots til five mile final

1846:57 N179GA roger sir

1846:59 STL-AS grand aire one seventy nine contact the tower one two zero point zero five

1847:03 N179GA one two zero zero five thank you sir

1847:22 N179GA i just (unintelligible) to dial it

1847:34 N179GA tower grand aire one seventy nine uh final for runway three fi uh three zero right

1848:00 N179GA tower grand aire one seventy nine uh established i l s for runway three zero right

1848:05 STL-NL grand aire one seventy nine saint louis tower loud and clear

1848:11 N179GA (unintelligible) for runway three zero right

1848:37 STL-L3 grand aire one seventy nine hold that speed as long as practical increase uh two zero knots if you're able caution wake turbulence following an embraer jet seven miles ahead

1848:45 N179GA uh gr maam grand aire one seventy nine duh we we might have to go ahead and declare an emergency here

1848:52 STL-NL grand aire one seventy nine saint louis tower roger continue state the nature of the emergency

1848:57 N179GA uh we uh lo looks like we gonna be uh short of un we uh we have make this approach one seventy nine

1849:05 STL-NL grand aire one seventy nine continue american seventeen ninety six turn left and contact ground point niner

1849:17 STL-NL grand aire one seventy nine uh give me the best speed you can to the airport you're cleared to land runway three zero right traffic on a three mile final

1849:24 N179GA oh cleared to land runway three zero right one seven nine

1849:46 STL-NL grand aire one seventy nine you need to maintain uh two thousand one hundred feet and maintain two thousand one feet until you intercept the glideslope please low altitude alert check your altitude immediately altimeter three zero two niner

1850:00 N179GA but we lost both engine we can't we have to make landing at sata uh anywhere sir

1850:06 STL-NL grand aire one seventy nine roger

1850:34 N179GA emergency emergency we're going uh we're going bo landing goin bo landing we're going (unintelligible)

1850:40 STL-NL grand aire one seventy nine roger we have equipment responding to your situation

1851:21 STL-NL grand aire one seventy nine radar contact

No further communications were received from N179GA.

The transcripts contain no record of a transmission from N179GA indicating a low fuel state prior to the 1845:42 transmission. The full transcript of communications are included in the public docket associated with this accident investigation.

FLIGHT RECORDERS

There were no flight recorders installed in the accident airplane.

WRECKAGE AND IMPACT INFORMATION

On April 9, 2003, the airplane was recovered from the Mississippi River and placed on a barge for examination. The airplane was recovered in two parts. The aft fuselage structure, including the tail surfaces and engines, was separated at the trailing edge of the wing. The aft fuselage remained attached to the forward fuselage by cables, wiring and plumbing. The wings remained attached to the forward section of the fuselage. Prior to the recovery, the airplane was almost completely submerged. Only the wing tips and the forward section of the fuselage at the break were visible prior to recovery. The nose cone of the airplane was recovered from the shore of the river upstream of the main wreckage.

The engines were examined and all rotating components rotated freely. No visible damage to the compressor or bypass fan blades was observed on either engine. Control system continuity in the aft fuselage was verified from the tail surfaces to the fuselage break. The control system push-pull rods exhibited deformation consistent with bending. The breaks in the push-pull rods were consistent with overstress failure.

The forward section of the fuselage and wings were examined. The nose landing gear and the right main landing gear were in the up and locked position. The left main landing gear was extended and the up-lock hook was broken. The flight control system was examined and continuity was verified for the rudder and elevator controls from the cockpit to the fuselage break. Aileron control system continuity was verified from the cockpit to the pressure seal box at the leading edge of the wing. The push-pull rod end immediately ahead of the pressure seal box was broken at the bellcrank. The break was consistent with overload failure. The push-pull rods running from the pressure seal box and along the leading edge of the wing had several breaks. All of these breaks had signatures consistent with overload failure. Aileron control system continuity from the farthest outboard push-pull rod break to the control surfaces was verified.

The fuel tanks were drained and a large amount of water was drained from each wing tank. No measurable quantity of fuel was recovered during the draining process.

Subsequent to the accident, the fuel totalizers for the left and right engine fuel flow read 2,978 and 2,944 pounds respectively.

TESTS AND RESEARCH

A fuel receipt was obtained from a fuel supplier at the departure airport. The receipt showed that the airplane was fueled with 700 gallons (4,760 pounds) of Jet-A fuel on the day of the accident.

14 CFR Part 91.169 entitled "IFR flight plan: Information required" states:

(a) Information required. Unless otherwise authorized by ATC, each person filing an IFR flight plan must include in it the following information:

(1) Information required under § 91.153(a) of this part;

(2) Except as provided in paragraph (b) of this section, an alternate airport.

(b) Paragraph (a)(2) of this section does not apply if:

(1) Part 97 of this chapter prescribes a standard instrument approach procedure to, or a special instrument approach procedure has been issued by the Administrator to the operator for, the first airport of intended landing; and

(2) Appropriate weather reports or weather forecasts, or a combination of them, indicate the following:

(i) For aircraft other than helicopters. For at least 1 hour before and for 1 hour after the estimated time of arrival, the ceiling will be at least 2,000 feet above the airport elevation and the visibility will be at least 3 statute miles.

(ii) For helicopters. At the estimated time of arrival and for 1 hour after the estimated time of arrival, the ceiling will be at least 1,000 feet above the airport elevation, or at least 400 feet above the lowest applicable approach minima, whichever is higher, and the visibility will be at least 2 statute miles.

14 CFR Part 91.167 entitled "Fuel requirements for flight in IFR conditions" states:

(a) No person may operate a civil aircraft in IFR conditions unless it carries enough fuel (considering weather reports and forecasts and weather conditions) to--

(1) Complete the flight to the first airport of intended landing;

(2) Except as provided in paragraph (b) of this section, fly from that airport to the alternate airport; and

(3) (3) Fly after that for 45 minutes at normal cruising speed or, for helicopters, fly after that for 30 minutes at normal cruising speed.

(b) Paragraph (a)(2) of this section does not apply if:

(1) Part 97 of this chapter prescribes a standard instrument approach procedure to, or a special instrument approach procedure has been issued by the Administrator to the operator for, the first airport of intended landing; and

(2) Appropriate weather reports or weather forecasts, or a combination of them, indicate the following:

(i) For aircraft other than helicopters. For at least 1 hour before and for 1 hour after the estimated time of arrival, the ceiling will be at least 2,000 feet above the airport elevation and the visibility will be at least 3 statute miles.

(ii) For helicopters. At the estimated time of arrival and for 1 hour after the estimated time of arrival, the ceiling will be at least 1,000 feet above the airport elevation, or at least 400 feet above the lowest applicable approach minima, whichever is higher, and the visibility will be at least 2 statute miles.

ADDITIONAL INFORMATION

As a result of the investigation of the January 25, 1990 crash of an Avianca Airlines Boeing 707 in New York, the Safety Board issued recommendation A-91-35 (attached) which recommended that the FAA address the incorporation of fuel planning and management procedures in transport category airplane flight manuals. The FAA responded that they did not agree with the recommendation, and the Safety Board classified the recommendation as "closed-unacceptable action." However, the FAA established an Aviation Rulemaking Advisory Committee (ARAC) Fuel Requirements Working Group (Federal Register announcement attached) tasked with determining fuel supply requirements for international and overseas operations, developing regulatory language for the revision of 14 CFR Parts 121 and 135, and developing advisory material. In October 1993, the ARAC working group produced a draft Advisory Circular (AC) 120-xx in October 1993 (cover page attached) on fuel planning that was never published.

The FAA and Dassault Falcon Jet were parties to the investigation.