N56PA

Destroyed
Fatal

GATES LEAR JET 36AS/N: 023

Accident Details

Date
Wednesday, May 10, 2023
NTSB Number
WPR23FA185
Location
San Clemente Island, CA
Event ID
20230510130456
Coordinates
32.839382, -118.515680
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
3
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

The pilots’ loss of airplane control following a catastrophic fire that started on the left side of the aft equipment bay (tail cone). The fire likely initiated from a leak from the left fuel motive flow line due to a b-nut that loosened for reasons that could not be determined based on available evidence.

Aircraft Information

Registration
Make
GATES LEAR JET
Serial Number
023
Engine Type
Turbo-fan
Year Built
1976
Model / ICAO
36ALJ36
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2
Seats
10
FAA Model
36A

Registered Owner (Current)

Name
PHOENIX AIR GROUP INC
Address
177 HIGHWAY 61 SE
City
CARTESVILLE
State / Zip Code
GA 30120
Country
United States

Analysis

HISTORY OF FLIGHTOn May 10, 2023, at 0749 Pacific daylight time, a Gates Lear Jet 36A, N56PA, was destroyed when it was involved in an accident near San Clemente Island, California. Both pilots and the additional crewmember were fatally injured. The airplane was operating as a Title 14 Code of Federal Regulations Part 91, other work use flight.

Witness interviews, ADS-B data, Air Traffic Control Transcripts, and flight data from the accident airplane’s left engine Digital Electronic Engine Control (DEEC) Incident Recorder were compared and correlated to establish a sequence of events and an approximate timeline (figure 1).

The airplane departed Point Mugu Naval Air Station (NTD), Oxnard, California about 0723 as the lead airplane in formation with a second Lear Jet utilizing the callsigns FENIX01 (N56PA) and FENIX02 (N544PA). The purpose of the flight was to participate in training exercises with the United States Navy in Warning Area 291 (W291). The flight proceeded south towards San Clemente Island with FENIX02 flying in formation with FENIX01.

About 0740, after entering W291 at 15,000 ft msl, FENIX02 (positioned on the right side of FENIX01) observed FENIX01’s flaps partially deploy. They asked the pilots of FENIX01 if they had deployed flaps, and they replied that they didn’t think so. FENIX02 then observed the flaps retract and seconds later observed white or gray colored smoke coming from the left, aft side of the airplane.

FENIX02 notified FENIX01 of the smoke and FENIX01 responded that they detected an odor in the cabin. At this point the aircrew of FENIX02 believed FENIX01 was no longer flying on autopilot because the airplane was “lightly rocking and pitching.” FENIX02 then observed pink fluid coming from the tail section of the airplane and informed FENIX01 that they had a hydraulic leak.

FENIX02 then observed flames coming from around the aft equipment bay access door and told FENIX01 that they were on fire. At 0740:30 FENIX01 started a left, descending turn and declared an emergency with the Navy area controller at 0741:00. They stated their intentions to land at San Clemente Island Naval Auxiliary Landing Field (NUC), which was about 32 miles north of their position. Shortly thereafter FENIX02 observed the drag chute, mounted on the aft equipment bay access door, depart from FENIX01. FENIX02 then took over as the lead airplane for the formation and maneuvered in front of FENIX01. FENIX01 was last observed passing underneath FENIX02 from the left to right side as they descended between 9,000 and 7,000 feet msl. No additional radio transmissions were heard from FENIX01 from that point. According to the captain of FENIX02 there was an overcast marine layer of clouds below them from about 2,000 ft to 4,000 ft msl that obscured most of San Clemente Island and NUC.

FENIX01 subsequently made a series of right-hand descending turns, during which the DEEC recorded several additional faults between about 0745:43 and when the DEEC data ended about 0746:32 following indications of a loss of power to the DEEC. The last recorded ABS-B data point at 0749:11 showed the airplane at 1,338 ft and heading northwest about ½ mile off the southwest side of San Clemente Island (figure 1) and was about 4 miles southeast of where the airplane’s wreckage was later located.

Figure 1 – Flight Path and Sequence of Events WRECKAGE AND IMPACT INFORMATIONThe airplane wreckage was located in the Pacific Ocean about 13 miles south of NUC and about 1.5 miles west of San Clemente Island at a depth of about 300 ft. The identified wreckage debris field was surveyed using sonar equipment and remotely operated vehicles (ROV). The debris field extended several hundred feet along the ocean floor in a northwest direction. A portion of the airplane was able to be recovered in October, 2023.

Investigators examined the wreckage two different times. The wreckage was fragmented and exhibited corrosion consistent with saltwater immersion. It was estimated that about 40% of the airplane was recovered (figure 2). The identifiable wreckage included portions of the nose cone, cockpit instrument panel, cabin floorboard, portions of both wings, both engines and nacelles, some components from the aft equipment bay, and the vertical stabilizer and left horizontal stabilizer.

Impact damage and a lack of complete wreckage prevented verification of flight control continuity.

Figure 2 –Portions of the Airplane Recovered (Highlighted in Green)

Main hydraulic system components consisting of the hydraulic reservoir, accumulator, pressure filter, return filter, and auxiliary hydraulic pump were identified and examined. The input ports of both left and right hydraulic shut off valves that were attached to the hydraulic reservoir were probed and found that the left valve was in the closed position and the right valve was in the open position. The flap control valve was not located.

Both engines were separated from the airplane structure when examined. Both engines’ fan blades and first stage compressor blades exhibited bending opposite of rotation. Neither engine was able to rotate to verify internal continuity and both engines exhibited corrosion degradation. No mechanical anomalies were noted with either engine during examination.

The left fuel motive flow line was intact from the fuel pump up to the fuselage fitting, where the line normally passes through the fuselage skin into the aft equipment bay near the aft left engine mount. The fuselage fitting on the aft equipment bay side did not have a b-nut attached nor the line that should connect the fitting to the motive flow valve. The left engine hydraulic pressure line and inlet total pressure (PT2) line, which pass through the fuselage into the aft equipment bay adjacent to the motive fuel line, each had aluminum b-nuts present on the interior side of their respective fuselage fittings and the interior lines for each was sheared at the fitting (figure 3).

Figure 3 – Left Fuselage Fittings and B-Nuts

The left fuel motive flow fuselage fitting and the hydraulic fluid return fitting were examined. Both were steel bulkhead type fittings, and both fittings were corroded. No thermal damage was observed on the outboard nuts and attached portions of tubing. On the inboard side, the motive flow fitting was missing the aluminum nut and tubing. Examination of the threads on the inboard side of the motive flow fitting did not exhibit evidence of thread stripping. The hydraulic fluid return fitting still had the aluminum nut attached on the inboard side and the aluminum tubing had sheared at the nut face. According to the operator, there was no record of maintenance being performed on the motive flow fitting and b-nut since the airplane had been assembled.

Portions of the wreckage exhibited exposure to heat and fire. See the Fire section of this report for a detailed description of those findings. ADDITIONAL INFORMATIONDigital Electronic Engine Control (DEEC) Incident Recorder

The left and right engine DEECs are installed adjacent to each other in the upper, left side of the aft equipment bay, aft of the left engine pylon. A single DEEC, from the left engine, was recovered during examination of the wreckage. The DEEC included an incident recorder which collects the following parameters in non-volatile memory (NVM): N1 (Low Pressure spool % speed), N2 (High Pressure spool % speed), ITT (inter-turbine temperature), WOW (weight-on-wheels), Mach, PLA (power lever angle), ALT (pressure altitude), TR (thrust reverser deploy), Control Mode (auto / manual), and Buffer Location Pointer. Data from the accident flight was recovered. For this particular version of the DEEC, the values for weight on wheels (WOW), Mach number, altitude, and thrust reverser (TR) deployment are internally calculated values and are not directly obtained from the aircraft.

The data recorded 5,120 seconds of data (about 85 minutes). The data includes the cruise, descent, and landing from the flight before the accident and the full data recorded from the accident flight. The accident flight dataset appears to start at about time stamp 1,980 seconds, determined by comparison with the Data File Chronology. At time stamp 50 seconds through the remainder of the dataset, the N2 and PLA parameters indicate N2 Signal Fail and No Valid Data respectively. This coincides with faults indicating a failure of the FCU PLA circuit and the N2 Monopole Circuit being open or shorted consistent with damaged wiring. Per system design the DEEC reverted to manual mode.

Data recovered from the incident recorder associated with the accident flight is displayed in figure 7. For purposes of determining the actual time of the events, there is a PLA increase beginning at about 1430 seconds correlating to the throttles being advanced for takeoff. Six seconds later N1 stabilizes at 101 percent and Mach data begins indicating an increasing trend from zero, consistent with the start of the takeoff roll. The DEEC data was correlated with ADS-B data for the airplane, which showed the takeoff roll began about 0722:48. The DEEC recorded the first fault about 0741:46 and the incident recorder data subsequently ends about 0746:32.

Figure 7 – DEEC Incident Recorder Data

Systems Descriptions

The following system descriptions were extracted from the Learjet 35/35A/36/36A Maintenance Manual.

Hydraulic System

The hydraulic system supplies military standard hydraulic fluid (MIL-H-5606) under pressure of approximately 1,450 psi to the brake, landing gear, flap, and spoiler systems.

Hydraulic fluid for systems operation is supplied from a reservoir through hydraulic supply shutoff valves to the engine-driven hydraulic pumps. The hydraulic reservoir is pressurized to approximately 20 psi by a pressure regulator. The pressure regulator is installed in a line from the bleed air duct to the reservoir. The engine-driven hydraulic pumps supply hydraulic fluid under pressure through check valves an...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR23FA185