Aviation Accident Summaries

Aviation Accident Summary MIA00GA083

Aircraft #1

N474AW

Rockwell OV-10D

Analysis

On the first mission, the pilot was forced to return to base, because the right engine chip detector light came on during the spray run. Maintenance personnel checked the airplane, and after the maintenance was performed it was revealed that the chip detector was found to have some fuzz on the probe. The engine was run, all checks of the engine were normal, and the aircraft was placed back into service. Just after takeoff, on the second mission, the pilot of N474AW reported to the pilot of the lead aircraft, that he was having problems, that he had lost power on No. 2 engine (right), that he could not maintain altitude and said, "it's going in with me." The lead pilot saw him eject from the aircraft, witnessed the fireball as the aircraft impacted in rising terrain, and saw the parachute open, but no seat separation. The pilot of N474AW said, "...the first indication that [he] got was that I felt the airplane start to yaw a little bit...[the] right engine was starting to spool down...[he] reached up and hit the hydraulic dump, to dump the [internal] load." He did not dump the external wing tanks, as is called for in the emergency engine failure checklist. He said "...[he] could [not] get the prop to feather...it was still slowly dying and it wasn't just a catastrophic failure...it was just like it was a slow dying process...and the airplane wouldn't climb...and the prop still wasn't in the feather...I was still flying into what I believed to be rising terrain I couldn't gain any altitude...I determined that I wasn't going to make it, that the airplane was going to wind up in [a] ditch. The pilot described checks he performed on the right engine, but did not mention anything about adding power to the left engine, as called for in item number one of the emergency engine failure check list. The pilot then elected to eject from the airplane. The maximum gross weight for the accident aircraft was 15,000 pounds. On the accident flight the calculated gross weight was 15,500 pounds. After dumping the internal load the calculated weight at impact was 13,056 pounds. According to item # 3, of the engine failure checklist, "External stores and Hooper load...JETTISON, AS REQUIRED." The external load was not jettisoned. Teardown and examinations of both engines and both propellers did not reveal any discrepancies. The calculated density altitude (DA) at the time of the accident was 2,540 feet. A simulated flight in an OV-10D was conducted, in an attempt to duplicate the accident flight. In the opinion of the two pilots that performed the tests, "...It is very possible...an OV-10 configured similarly as [the test airplane]...could perform safely and accomplish a climb if appropriate emergency procedures [as] outlined in [the] OV-10...Pilot's Pocket Checklist are employed...if the same procedures are followed in the checklist...regarding jettison of 'external stores and hopper load, drag index would be reduced to 50. With reduced drag index, performance would exponentially increase."

Factual Information

HISTORY OF FLIGHT On February 6, 2000, about 0905 eastern standard time, a Rockwell OV-10D, N474AW, call sign Bronco Two, owned by the United States Department of State (DOS), reportedly lost power during climb and impacted with the ground about 3 miles southwest of the departure runway near Larandia, Colombia. Visual meteorological conditions prevailed at the time, and a company VFR flight plan was filed for the DOS public-use eradication flight. The airplane was destroyed. The commercial-rated pilot was seriously injured, after he ejected from the airplane. The flight had originated from the same airport about 3 minutes earlier. The pilot of the lead airplane (call sign Bronco One), had taken off, and stated that after takeoff, "...I reported in the air...[the pilot of N474AW] reported he was initiating his take-off roll, I did not hear him call he was in the air, I asked him if he was in the air, he called out that he was having problems and that he had lost power on No. 2 engine (right). I immediately initiated a 180 degree turn to form up with him, it was at that time that I saw [N474AW] dumping his internal load, I caught up with him...on his right side about 150 to 200 feet above him and about one aircraft length behind him, I asked him if the aircraft was gaining any altitude and his reply was 'it's going in with me.' I replied get rid of the external tanks, it was at that time I saw him eject from the aircraft and simultaneously witnessed the fire ball as the aircraft impacted in rising terrain...I had seen the parachute open, but no seat separation...as I executed a left 360 degree turn I saw he was down and was moving." A satellite imagery (SATLOCK Tracking) showing the flight path and speed of N474AW before impact revealed that at the departure end of the runway the altitude N474AW had reached was 864 feet [above airport elevation of 873 feet], or 9 feet agl (above ground level), and a speed of 120 mph. The highest altitude that N474AW reached was 1,171 feet (298 above airport elevation) and highest speed was 155 mph. The last altitude depicted was 149 feet above airport elevation and the speed was 118 mph. Just before impact the satellite data showed that the airplane turned to the left. (See the satellite imagery (SATLOCK Tracking), an attachment to this report). The pilot's statement of events was taken at his residence on February 24, 2000. The statement was recorded with his permission, and his attorney was present. The recording was transcribed and the pilot declined to sign the transcribed statement. According to the pilot on the first mission, the right engine chip detector light came on during the spray run. He called the lead aircraft and told him, "...that [he] had a master caution and...had a right chip light...we immediately broke off flying altitude and returned to base." At the time they were located about 40-50 nautical miles south of base. The pilot said, "...we came in and I shut the airplane down...and went in to pull the power levers back to put the props on the locks, it did not lock on the locks, and that had been the third instance of that airplane not locking that particular engine...on the locks...a mechanic there he noticed that the prop was not on the locks. He looked up into the aircraft and confirmed that I had the power lever all the way back and asked me...had I moved them prior to the rotation and I said no sir and so he actually took up what I thought to be a can of W-D 40 or whatever while the one mechanic was checking...the chip detector and draining the oil of the crankcase he actually greased the prop locks on both props." According to the statement of the maintenance supervisor, "...during the time the aircraft was in the parking spot to the best of my knowledge, we did not removed [sic] the prop spinners off either engine and lube the pitch locks." The pilot said he never deplaned the airplane. According to the pilot, "...the mechanic had checked the airplane, and told me it was ready to restart, I was still in the airplane, still strapped in. I restarted the engine, the number two engine, the right engine and everything was normal, everything ran normal, I didn't get any bad indications from any instrument. I set the chronometer when the engine started. The [engine] ran for about eight and a half minutes...they had checked with me, I hadn't had any indications on engine instruments chip light...I proceeded to start my number one engine, and started it, got everything booted up, my SATLOCK, the whole nine yards. By the time we got all that running it was probably...about 7 and a half minutes into the second engine run. So on a lapse time of about fifteen minutes...everything was normal on my engine instruments and he [lead, Bronco One] proceeded to take off...once he took off, I pulled into position did a full power run up, everything was fine, and no fault indications. Everything was in the green everything was normal. I don't exactly remember the exact torque readings that I got on...takeoff, but they were within the tolerances...for the...temperature...so I released brakes and started takeoff." According to the pilot, he rotated the airplane, pulled the gear up, but said, "...I don't remember...whether it was after I got the flaps up, but the airplanes are heavy, you lose a lot of lift and we had to climb a little hill and I tried to get the flaps, or bleed the flaps up as quickly as possible so it is possible that I had the flaps up I don't know l00 percent myself. The first indication that I got was that I felt the airplane start to yaw a little bit. When I felt the yaw I looked down at my engine instruments and my right engine was starting to spool down. When I saw that my right engine was starting to spool down, I reached up and I hit the hydraulic dump, to dump the load. I got a little mirror right here in the vein and I could see where the boom you can't actually see the dump occurring but you can see the refection of the dump and the boom of the airplane, so I knew I was dumping. I verified that it was the right engine that was spooling down to the right condition lever went all the way back into condition fuel instead of shutoff, and put in some left rudder trim to start taking up for some of the rudder pressures that I was having...or might have been right rudders, I don't remember, or I just retrimmed the airplane so it wouldn't have to holding so much rudder pressure. I checked the right engine and the prop wasn't set. I brought the condition lever back out of feather and the fuel shut off back up...I went all the way into normal flight altitude [attitude], but I cycled it part of the way out and then pulled it back, back into feather and the fuel shutoff to see if I could get the prop to feather, and it was still slowly dying and I mean it wasn't just a catastrophic failure or whatever it was just like it was a slow dying process. I was still at low altitude...one or two hundred-foot estimation above ground level at the spot after takeoff the ground does rise a little and I was turning...trying to turn five degrees or so into the good engine like I was taught to keep leveling low to starting turning into the good engine like I was taught to keep the left wing low and turning into the good engine. I was coming around to the left, and the airplane wouldn't climb. I looked back over my shoulder and the prop still wasn't in the feather and I brought it back out and tried cycling it one more time by this time the airplane was, I was still flying into what I believed to be rising terrain I couldn't gain any altitude, I saw a pasture...two hills, and my first reaction...was to ride the airplane in and try to belly it in on the second ridge. I realized part of the way into...the second ridge I was going to have to stretch...to the second ridge and I knew that the airplane was going to want to start torque rolling...with me and at that particular time I couldn't remember whether the...ejection seat, the front one went out to the left or went to the right but I didn't want to get into a roll of any kind of magnitude because I knew if I was rolling into the side of the seat...that I would just be punching myself into the ground rather than up in the air. It got to the point where...I said...I was going to make it to that second hill to be stretching the glide. I determined that I wasn't going to make it, that the airplane was going to wind up in that ditch. I looked down at the handle put my hand on the handle my left hand on the handle and put my right hand in my lap and put my head back against the chin-rest raised my chin a little bit and pulled the handle." The NTSB investigator-in-charge (IIC) asked the pilot if while going down the runway did it seem that the airplane had rotated at a normal spot. The pilot answered "yes." The pilot was asked what gave him the indication that the engine was spooling down. He said, "I got the yaw, I could feel the airplane, was yawing around and the engines stalled and the gauges on the right engine were just coming down. The fuel pressure was coming down, oil pressure...fuel flow...all the ones across the board were going down." In addition, he said no warning lights had come on. When the pilot first explained the actions he performed after he became aware that "...my right engine was starting to spool down," he never mentioned anything about the emergency checklist or the action he took reference the good engine (left). When prompted by the NTSB IIC, he said that while he was trying to feather the right engine, that he applied "maximum power" to the left engine. He remembered that the landing gear "was up," and he verified that the chemicals were dumping. In addition, he said the aircraft did not take on any different characteristics as the load was dumping. He said, "...it takes a good while for that load to dump out, it takes a little better than twenty seconds." He was not sure how many gallons of chemicals were loaded the second time. He said, "...[he] was... not positive. We had sprayed a partial load and then...came back...as to whether or not they actually took it back up to three hundred gallons or not...[he was] not sure." The pilot was asked if he ever consider dumping the wing tanks. He said, "...I considered it and I started to reach for the button, but...if I couldn't get that prop better, I was just fighting an inevitable battle, and...I would have dumped the tanks I might have given myself a few more seconds for the prop to feather out, I don't [know] if the prop ever feathered or whether it didn't, I can't testify to that. Both times that I looked out it had not feathered and like I say, by the time I had done it like a third time I was so low I was dodging trees to try to make the pasture." The pilot was asked to explain what he saw reference the maintenance performed to correct the chip detector light. He said, "...I can't remember that guy's actual name...[a mechanic] greased the props and basically oversaw the chip but the actual hands on wrenching was...I guess what you call the crew chief of the airplane that day and I really don't know the guy's name...he is the one that was actually draining the oil. He drained the oil while [a mechanic] sprayed the pump." Instructions were given as far as the engine run after the maintenance was performed. He said that he and the maintenance personnel had a conversation about it, and "...a thirty minute ground line [was needed], [and] there was conversation about that wasn't necessary...[one of the mechanics] made a wisecrack and when I made the comment that I did not want to be responsible for saying when that engine was ready to go, that I wanted them to give me a signal when enough ground time had been run on the engine so that I could leave." The accident occurred during the hours of daylight about 01 degrees, 29 minutes north, and 075 degrees, 32 minutes west. PERSONNEL INFORMATION Based on company records the pilot's flight hours at the time of the accident were 10,000 hours of total flight time in all aircraft, and 106 hours in this make and model airplane. In addition, he recorded 48 hours in the last 90 days, 21 hours in the last 30 days, and 1 hour in the last 24 hours. AIRCRAFT INFORMATION According to statements taken from maintenance personnel that worked on the airplane after it returned from the first mission. A mechanic (TZ) stated, "...[N474AW] taxied into the parking spot with both engines running and I advised the pilot to shut down both engines. We started to open the engine cowlings when I asked the pilot if he still had a chip light and [he] advised me that he only had a flicker once or twice, but that it never stayed on or did it flicker again...we continued to check out the engine chip detector to see if it had any metal chips on it. Upon removing the chip detector we noted there was a small amount of fuzz on the chip detector, no chips, we then decided to drain the oil from the gear case and inspect it for any metal, there was none noted. We then serviced the engine with about one-to-one half quarts of engine oil to bring the level back to normal...the chip detector housing and plug was reinstalled and saftied [sic]. We decided to run the aircraft for about 20 minutes to see if the light would come back on, it did not. The Quality Control [representative]...Lead [mechanic], myself [supervisor]...the pilot, and the mechanics agreed to this corrective action...everything looked good to us. We ran it [engine] for 20 minutes. The pilot gave us a thumbs up and we taxied him out of the parking spot to prepare for takeoff." The quality control (QC) representative working on N474AW was asked to check on how many hours the No. 2 engine had and what past work had been performed. According to the QC representative's statement, "...[he] pulled up the engine historical as well as the...engine oil samples, remembering samples where pulled just 2 days earlier, for routine 50 hour samples left and right [engines]. [The oil sample] information showed that the engine was installed 121 hours prior...on September 99. There has been no history prior with engine having chip lights...maintenance pulled the detector out and we all, as well as maintenance lead observed that there was what would be called fuzz, on the detector contact, we pulled the housing to drain oil inside the gear box, noted nothing additional. The decision was made since there were no actual chips on the detector and no history as well, to release the aircraft...with no problems noted the aircraft was released...it should be noted the aircraft was bore scoped for gearbox pinions...15 hours prior to the incident with no problems noted." METEOROLOGICAL INFORMATION The reported weather at the Larandia base camp at the time of the accident was; clear skies, visibility 10 sm, winds calm, temperature 82 degrees F, and the altimeter was 29.99 inches Hg. The calculated density altitude (DA) at the time of the accident was 2,540 feet. MEDICAL AND PATHOLOGICAL INFORMATION The pilot injured his back due to the ejection seat was operated outside of its envelope precipitating subsequent lack of seat separation causing the pilot and the seat to impact with the ground at the same time. Toxicological tests were conducted at Foundation Santa Fe of Bogota, Columbia, and revealed, "No ethanol or drugs detected." WRECKAGE AND IMPACT INFORMATION The airplane impacted in rolling hilly terrain, about 3 miles from the departure airport. The flight path of the airplane just before impact was about 175 degrees. The airplane caught fire upon impact and shed parts. The debris field was on a heading of 240 degrees. The first ground scars observed along the wreckage path appeared to be oriented in the direction of flight. The first parts observed on the wreckage path were from the aft under belly spray apparatus. The right engine separated from the airframe, and the main wreckage came to rest about 3,000 feet from the first parts observed along the wreckage path. Both engines and propellers were shipped to Patrick Air Force Base, for a more detailed examination. A photograph taken by the

Probable Cause and Findings

A loss of power in the right engine due to undetermined reasons and the pilot's failure to maintain control of the airplane. Factors in this accident were; the pilot did not perform a weight and balance calculation, (airplane overweight at takeoff); the pilot's failure to follow the emergency checklist, and not jettisoning the external load.

 

Source: NTSB Aviation Accident Database

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