Accident Details
Probable Cause and Findings
The flight crewmembers’ misidentification of the damaged engine (after leveling off the airplane and reducing thrust) and their use of only the damaged engine for thrust during the remainder of the flight, resulting in an unintentional descent and forced ditching in the Pacific Ocean. Contributing to the accident were the flight crew’s ineffective crew resource management, high workload, and stress.
Aircraft Information
Registered Owner (Current)
Analysis
HISTORY OF FLIGHTOn July 2, 2021, about 0145 Hawaii-Aleutian standard time, Rhoades Aviation flight 810, dba Transair flight 810, a Boeing 737-200, N810TA, experienced an engine anomaly shortly after takeoff from Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii, and was subsequently ditched into Mamala Bay (in the Pacific Ocean), about 5.5 miles southwest of HNL. The captain sustained serious injuries, the first officer sustained minor injuries, and the airplane was destroyed. The flight was operating under Title 14 Code of Federal Regulations Part 121 as a cargo flight from HNL to Kahului International Airport (OGG), Kahului, Hawaii.
The flight crew arrived at Rhoades Aviation’s flight-following office at HNL by 0015 for the flight to OGG, which was scheduled to depart at 0100. The flight was the first of the day’s six planned flight legs for the captain and first officer. According to postaccident interviews, the flight crew discussed the weather for the flight and other related information. The captain then determined the performance limitations of the airplane and provided that information to the flight follower, who in turn provided the information to the cargo load manager. The flight crewmembers monitored cargoloading activities, and the cargo load supervisor gave the crewmembers the weight and balance paperwork.
The first officer conducted a preflight external inspection of the airplane. He found dried fluid that appeared to have leaked onto the right main landing gear. The first officer reported his findings to the captain, who examined the area with a mechanic. They determined that no active leak was occurring, the landing gear hydraulic reservoir had an appropriate amount of fluid, and the dried fluid was not a concern.
According to the CVR, the flight crew completed the Before Engine Start checklist at 0119:33 and the Engine Start checklist at 0120:01. During a postaccident interview, the captain stated that both engines started normally. At 0123:08, the tower controller cleared the airplane to taxi to runway 8R; the flight crew reported that the airplane left the gate behind schedule because of delays with cargo loading. The flight crew began the Taxi checklist at 0124:45, and the captain recalled that the engine indications looked normal at that time. After taxiing the airplane onto the runway, the first officer recalled that he brought up the power to an EPR level of 1.4 and then asked the captain to set the thrust. The captain adjusted the thrust until the EPR indications were at the carats (an EPR level of 2.01).
At 0132:20, the controller cleared the airplane for takeoff, and the first officer, who was the pilot flying, acknowledged the clearance. (The captain was the pilot monitoring.) At 0132:44, the flight crew completed the Before Takeoff checklist. The captain recalled that, during the takeoff roll, the EGT indications for both engines were at the line between the green (normal) and the yellow (caution) ranges on the displays. (The yellow range on the EGT display indicates temperatures between 520°C and 590°C; according to the Boeing 737 Aircraft Operations Manual, the maximum continuous EGT was 540°C.) During a postaccident interview, the captain stated that he had seen that EGT position during previous takeoffs and thus considered it to be normal.
According to the FDR, the engines were advanced to takeoff power starting at 0133:08, and both engines stabilized at an EPR consistent with takeoff; specifically, the No. 1 (left) engine was at 2.00 EPR, and the No. 2 (right) engine was at 1.97 EPR. According to the CVR, at 0133:13, the captain stated, “engines stable.” Between 0133:35 and 0133:46, the captain made the standard takeoff callouts, including “V1,” “rotate,” “V2” (takeoff safety speed), and “positive rate,” and the first officer made the callout “gear up.” The airplane flew a heading of 080°.
At 0133:52, the CVR recorded the sound of a “thud.” Starting about 2.5 seconds later, the CVR recorded the sound of a low-frequency vibration, the first officer stating an expletive, the captain stating “lost (an) engine,” and both pilots noting that the right engine had lost power. FDR data showed that, as the airplane climbed through an altitude of about 390 ft mean sea level (all altitudes in this report are mean sea level unless stated otherwise) while the airplane was at an airspeed of 155 knots, the EPR for the right engine dropped suddenly to 1.43; the EPR for the left engine remained at a level of about 2.00. (The only engine parameter that the accident FDR recorded was EPR.) The left rudder pedal then moved to a position consistent with the application of about 5.5° of left rudder. During postaccident interviews, the crewmembers recalled that the airplane yawed to the right and that the first officer corrected the yaw with the left rudder pedal. In addition, when the loss of thrust on the right engine occurred, the airplane banked 2° to the left; immediately afterward, the airplane banked 3° to the right.
About 0134:22, the captain stated, “I’ll give you flaps up,” and the first officer acknowledged this statement. During a postaccident interview, the captain stated that, after setting the flaps, he reduced thrust to maximum continuous thrust. FDR data showed that, during a 2.6-second period ending about 0134:28, the EPR for the left engine decreased from 1.96 to 1.91.
The captain’s initial notification to the controller about the emergency occurred at 0134:29; at the end of that transmission, the captain stated, “stand by.” The controller responded with a routine departure instruction, after which the captain again declared an emergency and repeated “stand by.” The captain then told the first officer that the airplane should climb to and level off at 2,000 ft (the airplane was at an altitude of 1,200 ft at that time) and fly a 220° heading. At 0135:16, the controller again provided the flight crew with routine instructions. One second later, the airplane reached its maximum altitude of 2,107 ft. Also at that time, the EPR on the left engine began incrementally decreasing from 1.91 to 1.83, 1.53, and 1.23 during the next 1 minute 17 seconds.
At 0135:35, the captain told the controller about the emergency for the third time, stating, “we’ve lost an engine…we are on a two twenty heading…maintaining two thousand [ft]…declaring emergency.” About that time, the airplane’s airspeed reached a maximum of about 252 knots. After this transmission, the CVR recorded the controller stating, “say again heading two four zero.” Immediately after issuing this instruction, the controller informed the captain that the heading was intended for another airplane on the same radio frequency. At 0135:55, the controller cleared the airplane for a visual approach to runway 4R at HNL and stated that the airplane could turn toward the airport. The captain responded, “we’re gonna have to run a checklist” and “we’ll let you know when we’re ready to come into the airport.” At 0136:08, the controller asked the flight crew to keep her advised, and the captain acknowledged the transmission. The exchange between the captain and the controller ended at 0136:22.
While that exchange was occurring, the EPR for the left engine decreased to 1.05 (at 0135:56), which was consistent with a power level near flight idle. The EPR for the left engine remained at this level for the remainder of the flight; 8 seconds later, the EPR for the right engine began to decrease below a level of about 1.4. At 0136:20, the airplane began to descend from 2,000 ft, reaching an altitude of 1,659 ft before beginning to climb again. At 0136:34, the captain stated, “two forty heading.” About 13 seconds later, the controller requested more information about the flight, including which engine was affected, and the captain responded, “we'll give you all that in a little bit.”
At 0137:06, the captain stated that the airplane should maintain an airspeed of 220 knots. During a postaccident interview, the captain stated that the 220-knot airspeed would be “easy on the running engine.” FDR data showed that, at 0137:09, the EPR for the right engine reached 1.09, which was also consistent with a power level near flight idle.
At 0137:13, the captain announced his intention to take control of the airplane, which the first officer acknowledged. FDR data showed that the airplane’s altitude at the time was 1,690 ft and that its airspeed was 224 knots. At 0137:36, the captain stated, “let's trim this up at two thousand [ft]”; at that time, the airplane’s altitude was 1,878 ft and airspeed was 196 knots. Four seconds later, the captain stated, “let’s see what is the problem…which one…what’s going on with the gauges,” and “who has the E-G-T?” The first officer stated, “it looks like the number one [engine].”About that time, the EPR on the left and right engines was 1.05 and 1.12, respectively. At 0137:54, the captain asked, “number one is gone?” The first officer replied that the left engine was “gone” and that “we have number two”; at 0137:58, the captain repeated “we have number two” and stated “okay.” Between 0137:59 and 0138:10, the right EPR level (which had been slowly increasing after reaching a level of 1.09) increased quickly from 1.12 to 1.18.
At 0138:16, the first officer asked, “should we head back toward the airport…before we get too far away?” The captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain recalled that he intended to climb the airplane to 2,000 ft and stay 15 miles from HNL to avoid traffic and have time to address the engine issue. He also recalled that there was no need to rush because there was no fire and an engine “was running.”
The captain called for the “engine failure shutdown checklist” and then stated, “I have the radios.” At 0138:43, the captain notified the controller that the airplane could turn to the right toward the ai...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# DCA21FA174