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National Transportation Safety Board Washington, D.C. 20594 PRSRT STD Postage & Fees Paid NTSB OFFICIAL BUSINESS Penalty for Private Use, $300 Permit No. G-200 In-Flight Engine Failure and Subsequent Ditching Air Sunshine, Inc., Flight 527 Cessna 402C, N314AB About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport, Great Abaco Island, Bahamas July 13, 2003 Aircraft Accident Report NTSB/AAR-04/03 PB2004-910403 Notation 7671A National Transportation Safety Board National Transportation Safety Board Washington, D.C. Washington, D.C. this page intentionally left blank Aircraft Accident Report E SA NTSB/AAR-04/03 PB2004-910403 Notation 7671A Adopted October 13, 2004 R A N S PO FE RI P LU B US UNUM T Y B OA AT I O N NATI ON LT RT A In-Flight Engine Failure and Subsequent Ditching Air Sunshine, Inc., Flight 527 Cessna 402C, N314AB About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport, Great Abaco Island, Bahamas July 13, 2003 R D National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2005. In-Flight Engine Failure and Subsequent Ditching, Air Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport, Great Abaco Island, Bahamas, July 13, 2003. Aircraft Accident Report NTSB/AAR-04/03. Washington, DC. Abstract: This report explains the accident involving Air Sunshine, Inc., flight 527, a Cessna 402C, which experienced an in-flight engine failure and was subsequently ditched about 7.35 nautical miles west-northwest of Treasure Cay Airport, Great Abaco Island, Bahamas. The safety issues discussed in this report include maintenance record-keeping and practices, pilot proficiency, Federal Aviation Adminstration (FAA) oversight, and emergency briefings. A safety recommendation concerning emergency briefings is addressed to the FAA. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at . Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2004-910403 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.1 The Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.1.1 Flight Check History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.5.2 The Director of Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.5.3 The Assistant Mechanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.1 Engines and Propellers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.6.1.1 Air Sunshine’s Approved Aircraft Inspection Program. . . . . . . . . . . . . . . . . . . . 10 1.6.1.2 Differential Compression Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.1.2.1 June 12 to 14, 2003, Differential Compression Checks . . . . . . . . . . . . . . . . 12 1.6.1.3 Time Between Overhauls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.12.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.12.2 Engines and Propellers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.15.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.15.2 Emergency Briefings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.15.3 Personal Flotation Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.15.4 Search and Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.16.1 Cessna Airplane Performance Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.16.2 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.16.3 Metallurgical Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.16.3.1 Right Engine Cylinder Assemblies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.16.3.2 Right Engine Pistons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.16.3.3 Right Engine Crankcase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Contents iv Aircraft Accident Report 1.16.3.4 Right Engine No. 2 Cylinder Hold-Down Studs and Through Bolts . . . . . . . . . 27 1.16.3.5 Cylinder Hold-Down Nuts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.17.1 Air Sunshine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.17.1.1 Air Sunshine’s In-Flight Engine Failure Procedures . . . . . . . . . . . . . . . . . . . . . . 30 1.17.1.2 Ditching Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.17.1.3 Company Record-Keeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.17.1.3.1 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.17.1.3.2 Aircraft Flight Logs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2 Federal Aviation Administration Oversight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2.1 General. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2.2 San Juan Flight Standards District Office Preaccident Oversight of Air Sunshine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.17.2.3 Fort Lauderdale Flight Standards District Office Postaccident Oversight of Air Sunshine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.17.2.4 San Juan Flight Standards District Office Postaccident Oversight of Air Sunshine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.17.2.5 Additional Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.18.1 Previous Ditching Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Airplane Performance After the Right Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Right Engine Failure Sequence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Cause of the Loosened No. 2 Cylinder Hold-down Nuts . . . . . . . . . . . . . . . . . . . . . . . . 40 Air Sunshine Maintenance Record-Keeping and Practices . . . . . . . . . . . . . . . . . . . . . . 41 Pilot Proficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Pilot Failure to Use Shoulder Harness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Emergency Briefings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4. Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 5. Appendix A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 v Aircraft Accident Report Figures 1. Interior configuration of the accident airplane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2. Cylinder differential compression check form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3. Exterior of the upper outboard engine cowling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4. The condition in which the right engine No. 2 cylinder retention system components were found. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 vi Aircraft Accident Report Abbreviations A&P AAIP ARTCC ATP CFI CFR CG CVR F FAA FDR FLL fpm FSDO Hg KIAS METAR MYAT MYGF PFD PIC PMI psi PTRS SB SJU SRQ airframe and powerplant Approved Aircraft Inspection Program air route traffic control center airline transport pilot certified flight instructor Code of Federal Regulations center of gravity cockpit voice recorder Fahrenheit Federal Aviation Administration flight data recorder Fort Lauderdale/Hollywood International Airport feet per minute Flight Standards District Office mercury knots indicated airspeed meteorological aerodrome report Treasure Cay Airport Grand Bahamas International Airport personal flotation device pilot-in-command principal maintenance inspector pounds per square inch Program Tracking and Recording System service bulletin Luis Munoz Marin International Airport Sarasota/Bradenton International Airport TBO TCM TSO time between overhaul Teledyne Continental Motors Technical Standard Order vii Aircraft Accident Report Executive Summary On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, following the in-flight failure of the right engine. Four of the nine passengers sustained no injuries, three passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane. The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 135 as a scheduled international passenger commuter flight from Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida, to MYAT. Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules flight plan. The National Transportation Safety Board determines that the probable cause of this accident was the in-flight failure of the right engine and the pilot’s failure to adequately manage the airplane’s performance after the engine failed. The right engine failure resulted from inadequate maintenance that was performed by Air Sunshine’s maintenance personnel during undocumented maintenance. Contributing to the passenger fatalities was the pilot’s failure to provide an emergency briefing after the right engine failed. The safety issues discussed in this report include maintenance record-keeping and practices, pilot proficiency, Federal Aviation Administration (FAA) oversight, and emergency briefings. A safety recommendation concerning emergency briefings is addressed to the FAA. this page intentionally left blank 1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On July 13, 2003, about 1530 eastern daylight time,1 Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.),2 flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, after the in-flight failure of the right engine. Two of the nine passengers3 sustained no injuries, five passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane.4 The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as a scheduled international passenger commuter flight from FLL to MYAT.5 Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules flight plan. The accident pilot was scheduled to fly the accident airplane on a 2-day trip sequence, which began about 0900 on July 12, 2003. The pilot flew five flights, each of which lasted about 1 hour, on the first day of the trip sequence. The last flight was from FLL to Sarasota/Bradenton International Airport (SRQ), Sarasota, Florida, and it arrived at SRQ about 1930. All of the first day’s flights were uneventful, and the pilot reported no engine- or airframe-related discrepancies for any of the flights. On July 13, 2003, the pilot arrived at SRQ about 0830 for the second day of the trip sequence. The pilot was scheduled to conduct five flights, each of which was to last about 1 hour. The first flight departed SRQ about 0930 and arrived at FLL about 1030. The second flight departed FLL about 1100 and arrived at MYAT about 1200. The third 1 Unless otherwise indicated, all times in this report are eastern daylight time. The airplane was not equipped with a cockpit voice recorder (CVR) and was not required to be so equipped. Therefore, all times referenced in this report are approximations, except for the takeoff time, which was determined by reference to transcripts of voice recordings obtained from the Fort Lauderdale/Hollywood International Airport (FLL) air traffic control tower and the Miami Automated International Flight Service Station. 2 Air Sunshine and Tropical Aviation Services are two separate companies owned and operated by the same people. 3 Four of the nine passengers were children; one of the children was under 2 years of age and was seated on an adult passenger’s lap during the flight. 4 The search for, and rescue of, the surviving airplane occupants (and recovery of the bodies of the two other airplane occupants) is discussed in section 1.15.4. 5 Under the provisions of Annex 13 to the Convention on International Civil Aviation, the investigation of an airplane crash is the responsibility of the state of occurrence (the state or territory in which an accident or incident occurs, which in this case was the Bahamas). However, the state of occurrence may delegate all or part of an investigation to another state by mutual arrangement or consent. At the request of the Bahamian Government, the National Transportation Safety Board assumed full responsibility for the investigation. The Bahamian Government designated an accredited representative to the investigation. Factual Information 2 Aircraft Accident Report flight departed MYAT about 1215 and arrived at FLL about 1330. All of the flights were reported to be uneventful. The pilot stated that, before departing on the fourth flight of the day, from FLL to MYAT, he conducted a preflight inspection of the airplane, which included checking the oil quantity. The accident flight was cleared for takeoff at 1427:11 and was estimated to last about 1 hour 10 minutes. During postaccident interviews, passengers stated that, before starting the engines, the pilot briefed6 them on the location of the personal flotation devices (PFD),7 the exits, and the safety briefing cards8 and on the need to keep their lapbelts fastened during the flight. One of the passengers who accompanied a child noted that the pilot’s briefing did not include how to handle children during an emergency and added that the briefing was “short and rushed.” The pilot and adult passengers stated that the cruise portion of the flight was uneventful, and the pilot stated that the engine instruments showed no indications of a mechanical problem. The pilot indicated that the flight’s cruise altitude was about 7,500 feet and that the cruise speed was about 160 knots indicated airspeed (KIAS).9 The pilot stated that, during the descent into MYAT, he maintained the same power setting that he used during cruise flight, which was about 2,300 rpm and 27 inches of mercury (Hg) manifold pressure. The pilot stated that, about 20 to 25 miles from MYAT (about 45 to 50 minutes into the flight), while descending to about 3,500 feet, he heard a bang and saw oil coming out of the right engine cowling.10 The adult passenger in the copilot’s seat (the seat to the right of the pilot seat) reported seeing a “stream of oil” coming from the right engine and stated that he notified the pilot of his observation. Several of the other adult passengers reported seeing white smoke coming from the right engine. These passengers stated that the smoke was followed 6 Title 14 CFR 135.117(a) requires pilots to brief passengers orally before departure. Section 135.117(a) states that the predeparture briefing should include, in part, information on the use of safety belts, the location of and instructions for opening the passenger entry door and emergency exits, and the location of survival equipment. 7 The airplane was equipped with 10 PFDs that were sealed in plastic pouches. Eight of the PFDs were stowed under the forward edge of each passenger seat. The PFDs for the pilot and copilot positions were stowed outboard of each pilot seat. For more information, see section 1.15.3. 8 The safety briefing cards were contained in the stowage pockets located on the back of each seat. 9 The airplane was not equipped with a flight data recorder (FDR) and was not required to be so equipped. Data from the Nassau Air Route Surveillance Radar (about 125 miles south of the accident site) did not indicate any targets in the Bahamas airspace consistent with the reported route and altitude of flight 527. Other aircraft were observed at an altitude of about 6,600 feet and above near Grand Bahamas Island and at an altitude of about 5,100 feet and above near the ditching site. All flight altitudes and speeds referenced in the report are based on the pilot’s recollections. 10 From June 12 to 14, 2003, Air Sunshine’s Director of Maintenance and an assistant mechanic performed differential compression checks on the accident airplane’s right engine cylinders during the airplane’s last recorded engine maintenance. For more information about these checks, see section 1.6.1.2.1. Factual Information 3 Aircraft Accident Report by a stream of oil and then the sound of a loud bang. They reported seeing parts falling from the engine after they heard the loud bang. The pilot stated that, after he heard the bang, he reduced power to the right engine. The pilot indicated that, at the time of the event, the airplane’s airspeed was about 135 to 140 KIAS. He added that the airspeed for a normal descent should be about 140 knots. The pilot stated that he then saw that the engine magnetos had penetrated through the engine cowling and that the magnetos were hanging from wires. He added that he did not see any other damage. He stated that he noticed that the right engine oil pressure indication was decreasing rapidly. He added that the fuel selector was “in the green” (that is, each engine was being provided fuel from its respective main fuel tank). He stated that he attempted to feather11 the right propeller and shut down the engine12 but that the propeller continued “wind-milling” (turning) slowly. The passenger in the copilot seat and the adult passenger in the seat behind the copilot’s seat also reported that the pilot tried to feather the right propeller but that it continued to turn after the engine failed.13 The pilot stated that, after he attempted to shut down the right engine, he applied full power to the left engine and tried to fly the airplane but that he could not maintain altitude. He stated that he slowed the airplane to “blue line” (single-engine best climb rate) airspeed, which is about 105 KIAS, and that, at that point, the airplane was at a descent rate of about 200 to 300 feet per minute (fpm). The pilot stated that he contacted Air Sunshine’s station manager at MYAT after trying to shut down the engine. The station manager stated that the pilot told him that the right engine had failed and that he was at an altitude of about 3,000 feet. The manager added that the pilot asked him to contact the company’s Director of Operations at FLL, which the manager did. Air Sunshine’s Director of Operations told the manager to ask the pilot if the propeller on the failed engine was feathered, and the pilot responded that it was. The Director of Operations then asked the manager to get the airplane’s distance from the airport, altitude, and descent rate; the pilot responded that he was about 15 miles from the airport14 at an altitude of about 2,000 feet with a descent rate of about 200 fpm. The Director of Operations instructed the manager to tell the pilot to “keep the good engine at full power, bank to the good engine and to just stay calm and fly the plane.” The pilot told the manager that he had already “done all of those things.” 11 Feathering means to rotate the propeller blades so that the blades are parallel to the line of flight to reduce drag and prevent further damage to an engine that has been shut down. 12 The pilot stated that he did not follow Air Sunshine’s procedures for an in-flight engine failure because he knew which engine had failed; therefore, he chose to immediately shut down the right engine. He added that he did not follow the engine failure checklist because he was “too busy flying the airplane.” For more information about Air Sunshine’s in-flight engine failure procedures, see section 1.17.1.1. 13 The pilot and both passengers reported that the right propeller continued turning until the airplane contacted the water. 14 The airplane was equipped with a global positioning system, which the pilot used to determine the airplane’s distance from the airport. Factual Information 4 Aircraft Accident Report The station manager stated that he then alerted local agencies about the emergency and instructed another Air Sunshine pilot, who had just taken off from Marsh Harbor, Bahamas, for FLL, to divert that flight toward flight 527 and follow the airplane until it reached the airport. The Air Sunshine pilot transmitted a distress call for flight 527, which the pilot of a nearby flight (Gulf flight 9267) heard and relayed to the Federal Aviation Administration (FAA) Air Route Traffic Control Center (ARTCC), Miami, Florida. The pilot stated that, after talking to the station manager, he slowed the airplane to about 95 KIAS to try to maintain altitude. The pilot stated that, once he descended from about 1,500 to 1,000 feet, he realized the airplane could not make it to the airport and that he would have to ditch the airplane. The pilot stated that he ditched the airplane parallel to the waves with the flaps retracted. He added that, at the time of the ditching, the winds were about 15 knots, and the outside air temperature was about 80° to 90° Fahrenheit (F). The passenger in the copilot seat stated that the pilot did a good job ditching the airplane. He stated that he noticed a placard on the instrument panel with instructions for ditching, which stated that the airspeed should be kept in the “blue zone,” and that the airspeed was within this zone during the ditching. Adult passengers described the contact with the water as “very hard.” They stated that the airplane landed “flat” and that it did not dive into the water. During postaccident interviews, the passengers stated that the pilot did not instruct them to retrieve their PFDs or to assume a brace position before contact with the water. The passengers stated that the only time the pilot addressed them after the right engine failed and before the airplane contacted the water was to tell them to “calm down.” The airplane was located at 26° 45.547' north latitude and 77° 31.642' west longitude. The accident occurred during daylight hours. 1.2 Injuries to Persons Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 0 0 2 0 2 Serious 0 0 0 0 0 Minor 1 0 5 0 6 None 0 0 2 0 2 Total 1 0 9 0 10 Factual Information 5 Aircraft Accident Report 1.3 Damage to Airplane The airplane sustained substantial damage. 1.4 Other Damage No other damage was reported. 1.5 Personnel Information 1.5.1 The Pilot The pilot, age 46, was hired by Air Sunshine in September 1995. He held an airline transport pilot (ATP) certificate, which was issued March 7, 1998, with a multiengine land rating. Additionally, he held a commercial pilot certificate with a single-engine land rating and a certified flight instructor (CFI) certificate with single-engine, multiengine, and instrument ratings. The pilot held an FAA first-class medical certificate, dated June 9, 2003, with no limitations. According to the pilot, he began flight training at Aviation Training, Hayward, California. The pilot reported that, before he began working for Air Sunshine, he worked as a first officer on Embraer 110 airplanes for Payam Aviation Services, Tehran, Iran, for 2 years. The pilot began working for Air Sunshine in September 1995, performing clerical work for about 6 months before starting the company’s flight training. He served as first officer on the company’s Embraer 110 for about 1 1/2 years, during which time he earned his ATP certificate. In 1998, he upgraded to captain on the Cessna 402. He resigned from Air Sunshine on September 29, 2002. From September 30 to November 11, 2002, the pilot received flight training at Arrow Air, Inc., in Miami.15 The pilot left Arrow Air because he could not complete the training.16 On November 23, 2002, the pilot was rehired by Air Sunshine. Air Sunshine records indicated that the accident pilot had accumulated a total flying time of about 8,000 hours, about 5,500 hours of which were as pilot-in-command (PIC) and about 5,000 hours of which were in Cessna 402 airplanes. He had flown about 251, 69, 13, and 6 hours in the last 90, 30, and 7 days, and 24 hours, respectively. The pilot’s last PIC line check occurred on July 9, 2002; his last PIC proficiency check occurred on January 14, 2003; and his last recurrent ground training occurred on June 14, 2003. A search of FAA records found no evidence of enforcement actions. 15 Arrow Air is a 14 CFR Part 121 supplemental all-cargo air carrier. During the time that the pilot was in training, the company operated McDonnell Douglas DC-8 and Lockheed L-1011 airplanes. 16 A review of Arrow Air’s simulator training records for the pilot revealed that he had received a large number of “unsatisfactory” grades. Further, the records indicated that the pilot needed to improve his scanning and checklist skills, including response and organization. Factual Information 6 Aircraft Accident Report FAA records revealed that the pilot had been involved in an incident on June 12, 1999, in which the nose landing gear collapsed during landing at FLL. The pilot and passengers were not injured, and the airplane sustained minor damage. The records also revealed that the pilot was involved in an accident on March 16, 2000, in which a tire failed during takeoff from FLL.17 The pilot aborted the takeoff but was unable to keep the airplane on the runway. The pilot and passengers were not injured, and the airplane received substantial damage. Further, a review of the FAA’s Program Tracking and Reporting System (PTRS) records revealed that, on September 13, 2000, the pilot failed a ramp check because his airplane was found to have numerous discrepancies and his passenger briefing was found to be inadequate. As previously stated, the pilot was scheduled for a 2-day trip sequence on July 12 and 13, 2003. Between 0900 and 1700 on July 12th, the pilot flew five flights and accumulated about 5 hours of flight time. All of the flights were conducted in the accident airplane. The pilot stated that, after the last flight (FLL to SRQ), he ate, watched some television, and went to bed between about 2230 and 2300. The pilot stated that he awoke about 0730 on July 13th and arrived at SRQ about 0830 to report for the second day of the trip sequence, which consisted of five scheduled flights starting about 0930. Each flight was expected to last about 1 hour. The pilot completed three of the scheduled flights before the accident flight occurred. 1.5.1.1 Flight Check History Between April 1983 and February 1998, the pilot received the following notices of disapproval from the FAA: • In April and May 1983, the pilot received notices of disapproval because he failed the entire flight test portion of the flight checks18 he was receiving for his private pilot certificate. On June 22, 1983, the pilot was rechecked successfully, and he received his private pilot certificate. • On October 30, 1985, the pilot received a notice of disapproval because he failed the “holding” and the “recovery from an unusual attitudes” portions of the flight check he was receiving for his instrument rating. On November 8, 1985, the pilot was rechecked successfully, and he received his instrument rating. • In December 1987 and February 1988, the pilot received notices of disapproval because he failed the entire flight test portion of the flight checks he was receiving for his CFI certificate. On March 17, 1988, the pilot was rechecked successfully, and he received his CFI certificate. 17 A description of this accident, MIA00LA109, can be found on the Safety Board’s Web site at . 18 If a pilot receives a notice of disapproval for a flight check, the pilot can be required to be rechecked on the complete flight check or on designated portions of the flight check. Factual Information 7 Aircraft Accident Report • In July 1988 and May 1989, the pilot received notices of disapproval because he failed the entire flight test portion of the flight checks he was receiving for his CFI instrument rating. In August 1989, he received another notice of disapproval because he failed the “holding” portion of the flight check and did not complete three other portions of the check. On December 8, 1989, the pilot was rechecked successfully, and he received his CFI instrument rating. • In February 1998, the pilot received a notice of disapproval because he failed the “nondirectional beacon approach” portion of the flight check he was receiving for his ATP certificate. On March 7, 1998, the pilot was rechecked successfully, and he received his ATP certificate. 1.5.2 The Director of Maintenance Air Sunshine’s Director of Maintenance was hired by the company in March 1997 as a mechanic; seven months later, he was promoted to Director of Maintenance. On October 28, 1989, the Director of Maintenance applied for his airframe and powerplant (A&P) certificate based on work experience19 he obtained while working as an assistant mechanic from March 1985 to the date of the application. On October 24, 1990, the director took the oral and practical examinations required by 14 CFR 65.79.20 He passed all of the oral examinations; however, he failed the following portions of the practical exam: Section I, General – Airframe and Powerplant, subsections (A) weight and balance and (B) completion of FAA Form 337; and Section IV, Powerplant Theory and Maintenance, subsection (A) troubleshooting of turbine engines. The director received additional training in these areas and retook the practical exam on October 30, 1990, at which time he received his A&P certificate. A search of FAA records found no evidence of enforcement actions. The Director of Maintenance reported that, from March 1985 to August 1990, he worked as an assistant mechanic on Cessna 402 airplanes at Airways International, a 14 CFR Part 135 on-demand charter operator in Miami. From January 1988 to March 1989, he also worked part-time as an assistant mechanic on McDonnell Douglas DC-10 and Lockheed L-1011 airplanes at Eastern Airlines in Miami. From mid-1990 to mid-1996, he worked as a mechanic at Airways International. From August 1996 to March 1997, he worked as a mechanic on Cessna 402, 210, and 206; Piper Cherokee; Britten-Norman Islander; and Beechcraft 55 and 58 airplanes at Flightline of America, Pembroke Pines, Florida. 19 According to 14 CFR 65.77, “Experience Requirements,” “each applicant [for a mechanic certificate or rating]…must present either an appropriate graduation certificate or certificate of completion from a certificated aviation maintenance technician school or documentary evidence of…at least 30 months of practical experience concurrently performing the duties appropriate to both the airframe and powerplant ratings.” 20 According to 14 CFR 65.79, “Skill Requirements,” “each applicant [for a mechanic certificate or rating]…must pass an oral and a practical test on the rating he seeks. The tests cover the applicant’s basic skill in performing practical projects on the subjects covered by the written test for that rating. An applicant for a powerplant rating must show his ability to make satisfactory minor repairs to, and minor alterations of, propellers.” Factual Information 8 Aircraft Accident Report 1.5.3 The Assistant Mechanic Air Sunshine’s assistant mechanic was hired by the company on June 6, 2000, to work in San Juan, Puerto Rico. In March 2003, he transferred to the company’s facility at FLL. The assistant mechanic did not have an A&P certificate. On March 31, 2003, the Director of Maintenance signed off a Certificate of Training for the assistant mechanic, indicating that he had completed 30 hours of basic indoctrination training. On April 30, 2003, the director signed off a Certificate of Training for the assistant mechanic, indicating that he had completed 60 hours of aircraft subjects training. On June 30, 2003, the director signed off a Certificate of Training for the assistant mechanic, indicating that he had completed 200 hours of on-the-job training for the “entire aircraft, airframe, engine, propeller, accessories, etc.” 1.6 Airplane Information The accident airplane, serial number 402C0413, was manufactured by Cessna Aircraft Company on November 24, 1980. The airplane was operated by several airlines21 before being sold to Tropical International Airlines, Inc.,22 on August 29, 1997. From mid-1997 to late 2000, the airplane was kept at the company’s maintenance facility at FLL. Air Sunshine’s President stated that, during this time, extensive maintenance was being performed on the airplane, including left and right engines and propellers replacement, sheet metal repair, corrosion treatment, and landing gear repair, to make it airworthy. Tropical International Airlines leased the airplane to Air Sunshine on November 1, 2000.23 The airplane was inspected in accordance with Air Sunshine’s FAA Approved Aircraft Inspection Program (AAIP) on November 20, 2000, and found to be airworthy.24 The airplane was added to the company’s operations specifications on December 6, 2000. The airplane was configured with a pilot seat (left side), a copilot seat (right side), and eight passenger seats. (See figure 1.) The airplane was equipped with a window escape hatch adjacent to the pilot seat (1A); an emergency escape hatch adjacent to seats 2B and 3B; and a two-section outward opening airstair door (main cabin door) adjacent to seats 4A and 5A, the lower portion of which was equipped with stairs. The pilot and copilot seats were equipped with lapbelts and single-strap shoulder harnesses, and the passenger seats were equipped with lapbelts. 21 On March 1, 1992, the airplane was involved in a nose landing gear collapse while being operated by Airways International. For more information about this accident, MIA92IA090, see the Safety Board’s Web site at . 22 Tropical International Airlines was owned and operated by the same people who own and operate Air Sunshine. 23 The lease agreement stated that Air Sunshine would be responsible for all expenses, including maintenance. 24 For more information about Air Sunshine’s AAIP, see section 1.6.1.1 Factual Information 9 Aircraft Accident Report Figure 1. Interior configuration of the accident airplane. According to the load manifest form for the accident flight, the airplane’s takeoff weight was about 6,644 pounds, including 890 pounds of passenger weight,25 350 pounds of baggage weight, and 800 pounds of fuel weight. The airplane’s takeoff center of gravity (CG) was 154.61 inches aft of the reference datum. After the airplane was retrieved from the water,26 the baggage was removed from the airplane, dried, and weighed. The baggage weighed 440.85 pounds, 90 pounds more than the amount that was entered on the load manifest form. After applying the additional 90 pounds, the weight and CG were still within acceptable limits.27 1.6.1 Engines and Propellers The airplane was equipped with two Teledyne Continental Motors (TCM) TSIO-520-VB reciprocating engines. These engines are turbo-charged and fuel-injected with six horizontally opposed air-cooled cylinders. The engines are rated for 325 horsepower at a power setting of 2,700 rpm with 39 inches Hg manifold pressure up to an altitude of 12,000 feet. 25 Actual passenger weights were used to calculate the total passenger weight. 26 The airplane was retrieved from the water on August 3, 2003. The retrieval was delayed because of choppy waters. 27 According to the Cessna 402C Pilot Operating Handbook, the airplane’s maximum gross takeoff weight is 7,210 pounds, and the maximum gross landing weight is 6,850 pounds. The maximum forward CG for flight 527 was 151.2 inches aft of the reference datum, and the maximum aft CG for the flight was 160.7 inches. Factual Information 10 Aircraft Accident Report The engine cylinders incorporate an overhead inclined valve design. The cylinders have updraft intake inlets and downdraft exhaust outlets mounted to the underside of the cylinder heads. Each of the six cylinders is attached to the engine case by a series of threaded studs, through bolts, and nuts. Six 7/16-inch, 20 threads-per-inch studs are threaded into the case half for exclusive use at each cylinder location and are held down by 6-point nuts. Additional studs are positioned between the cylinders and are shared by adjacent cylinders. Two 1/2-inch through bolts, which are located at the engine crankshaft main bearing positions, are either shared by opposed cylinders or the opposite crankcase half and are held down by 12-point nuts. The right engine, serial number 529092, and the left engine, serial number 811069-R, were manufactured by TCM on February 1, 1991, and January 1, 1997, respectively. Airmark Overhaul, Inc., in Fort Lauderdale28 overhauled the right and left engines on December 14 and December 21, 1999, respectively.29 At the time of overhaul, the right and left engines had times since new of 3,582.6 flight hours and 2,400.0 flight hours, respectively. The right and left engines were installed on the accident airplane on October 10 and 7, 2000, respectively. The last routine engine maintenance, which included changing the oil, inspecting the oil filter, looking for leaks, and performing a ground run-up, was conducted on July 8, 2003, and the time since overhaul for both engines at that time was 2,246.5 flight hours. At the time of the accident, both engines had a time since overhaul of 2,270.6 flight hours.30 The airplane was equipped with two McCauley Propeller Systems 3AF32C505-C three-bladed, dual-acting, constant-speed propellers. The blades are counterweighted to help move them toward higher blade angles (that is, toward feather) during operation. A feather spring inside the propeller moves the blades to the high-pitch (feather) stops. A centrifugal start-lock system, which uses spring-loaded pins that engage the piston as the propeller speed drops below approximately 600 rpm, prevents the blades from traveling all the way to feather during normal engine shutdowns, which reduces the load on the engine during subsequent engine starts. 1.6.1.1 Air Sunshine’s Approved Aircraft Inspection Program As a 14 CFR Part 135 operator, Air Sunshine had the option to operate either under the manufacturers’ maintenance inspection programs or to develop and receive FAA approval for its own maintenance inspection program. From 1982 to 1992, Air Sunshine operated under the manufacturers’ (Cessna, TCM, and McCauley Propeller) maintenance inspection programs. In early 1992, under the oversight of the Fort Lauderdale Flight Standards District Office (FSDO), Air Sunshine developed and received approval for its own inspection 28 Airmark Overhaul is an FAA-approved maintenance vendor for Air Sunshine. 29 Maintenance records were not available from the dates of manufacture of the right and left engines to the dates of the overhauls. 30 For information about TCM’s recommended overhaul limit and Air Sunshine’s overhaul interval, see section 1.6.1.3. Factual Information 11 Aircraft Accident Report program. The company’s initial AAIP was a 3-phase, 60-hour inspection program. A different phase was performed every 60 hours of operation along with a routine servicing check, which included an engine oil change, a ground run-up, and a visual inspection of the airframe. Phases 1 through 3 comprised one full cycle, and an airplane had to complete one full cycle (that is, the entire aircraft had to have been inspected) every 180 hours of operation. On November 4, 2002, Air Sunshine submitted revision No. 10, which proposed to change the company’s AAIP to a 6-phase, 60-hour inspection program, to the FAA for approval. On January 9, 2003, the FAA approved the change,31 and the 6-phase, 60-hour inspection program was in effect at the time of the accident. Each of the six phase inspections focused on one major airplane section. Phase 1 covered the powerplants, including a focused engine inspection and a differential compression check of the engine cylinders; phase 2 covered the wings; phase 3 covered the cabin; phase 4 covered the landing gear; phase 5 covered the fuselage; and phase 6 covered the empennage. Phases 1 through 6 comprised one full cycle, and an airplane had to complete one full cycle every 360 hours of operation. The last phase 1 inspection was performed at FLL from June 12 to 14, 2003. During this inspection, each engine was determined to have a time since overhaul of 2,187 flight hours. 1.6.1.2 Differential Compression Checks TCM Service Bulletin (SB) 03-3 states that differential compression checks are conducted to identify leaks in the engine cylinders and the sources of any leaks that were found and that leaks can be caused by abnormal or excessive wear inside the engine cylinders or their components, problems with the valves or valve seats, and cracks in the cylinders. The SB also states that compression checks should be conducted “at each 100 hour interval, annual inspection or when cylinder problems are suspected.”32 According to SB 03-3, before conducting the differential compression check, the acceptable pressure leakage limit for the equipment being used and the atmospheric conditions at the time that the check is conducted need to be established. SB 03-3 contains the following instructions on how to perform differential compression checks on all of its engines: • remove the most accessible spark plug from each of the six cylinders on each engine; • turn the engine crankshaft by hand in the direction of rotation until the piston is coming up on top dead center at the end of the compression stroke; 31 In early 1998, Air Sunshine requested that its operating certificate be transferred from the FAA’s Fort Lauderdale FSDO to its San Juan FSDO. The FAA granted the request, and the transfer took place on June 2, 1998. The company’s operating certificate was under the jurisdiction of the San Juan FSDO when the company applied and was approved to change its AAIP. For more information about FAA oversight of Air Sunshine, see section 1.17.2. 32 For information about the postaccident change to the differential compression check interval and other changes to Air Sunshine’s AAIP, see section 1.17.2.5. Factual Information 12 Aircraft Accident Report • install a cylinder adapter in the spark plug hole and connect a differential pressure tester to the cylinder adapter and slowly open the cylinder pressure valve and pressurize the cylinder to 20 pounds per square inch (psi); • continue to rotate the engine in the direction of rotation, against the pressure, until the piston reaches top dead center (that is, with the piston at the end of the compression stroke and the beginning of the power stroke); • open the cylinder pressure valve completely; • move the propeller slightly back and forth with a rocking motion while directing regulated pressure of 80 psi into the cylinder and adjust regulator as necessary to maintain a pressure gauge reading of 80 psi; and • record the pressure indication on the cylinder pressure gauge. The difference between the pressure directed into the cylinder (80 psi) and the cylinder pressure shown on the regulator pressure gauge is the amount of leakage through the cylinder. Any cylinder pressure level greater than that established as the acceptable pressure leakage limit indicates an acceptable operating condition for a reciprocating engine. The SB recommends that, if the cylinder pressure levels are less than the acceptable pressure leakage limit, cylinder borescope inspections should be conducted. 1.6.1.2.1 June 12 to 14, 2003, Differential Compression Checks As noted previously, the last differential compression checks performed on the accident airplane’s engines occurred from June 12 to 14, 2003, as part of the airplane’s last phase 1 inspection. According to the Director of Maintenance, he performed the checks on the left engine while the assistant mechanic watched and then recorded the readings in the inspection record. The cylinder differential compression check form33 in Air Sunshine’s Maintenance Manual contains the following: “CAUTION - It is recommended that someone hold the propeller during this check to prevent possible rotation.” (See figure 2.) The Director of Maintenance stated that, after completing the checks on the left engine, he asked the assistant mechanic if he felt capable of performing the checks on the right engine without supervision. The director stated that the assistant replied that he could perform the checks; as a result, the director left the assistant to perform the checks by himself without supervision. According to the director, he asked the assistant mechanic to record the compression check readings for the right engine on a sheet of paper so that he could review them before making the entries in the cylinder differential compression check form in the inspection records; however, the assistant mechanic recorded the readings directly in the inspection record. Figure 2 also shows the compression check readings (in psi) recorded in the inspection record by the assistant mechanic for both engines. Accounting for the check equipment used at the time that the checks were performed, the Safety Board determined that the acceptable pressure leakage limit was 54 psi. 33 The cylinder differential compression check form is part of the company’s AAIP phase 1 inspection package. Factual Information 13 Aircraft Accident Report Figure 2. Cylinder differential compression check form. Note: According to the assistant mechanic and the Director of Maintenance, the number recorded for right engine cylinder No. 3 was “55.” (Safety Board investigators who reviewed the document noted that the number could be either “55” or “25.”) The assistant mechanic’s signature and A&P certificate number have been redacted. Factual Information 14 Aircraft Accident Report During postaccident interviews, the assistant mechanic stated that he had never performed a differential compression check before conducting the checks on the accident airplane’s right engine. The assistant stated that his normal duties included changing oil, tires, cables, and spark plugs and cleaning the airplane. When a Safety Board investigator asked the assistant how to perform the compression check, he stated only that the spark plugs had to be removed from the cylinders and that the piston had to be at top dead center on its compression stroke. The Director of Maintenance stated that, as he was reviewing and signing off on the day’s maintenance work, he noticed that two of the readings obtained from the compression checks of the right engine (0 psi for the No. 2 cylinder and 20 psi for the No. 4 cylinder)34 were “highly questionable.” The director stated that he asked the assistant mechanic if he had been careful to get the piston at top dead center on its compression stroke on each cylinder when he performed the check. The director indicated that, although the assistant stated that he had been careful to get the piston into its required position, he appeared uncertain when asked specifically about the two questionable cylinder readings. The director told the assistant mechanic that the compression checks on the right engine cylinders would have to be repeated. According to the Director of Maintenance, after he repeated the checks on the right engine, all of the cylinder’s compression readings were in the 70-psi range, including the two cylinders with low readings from the first compression checks. The director stated that, when he did the rechecks, he was careful to get the piston at top dead center on its compression stroke and hold the propeller while adding the pressure. He added that, if the compression level readings had remained low, he would have grounded the airplane. The director stated that he had the assistant mechanic observe the checks and record the readings on a sheet of paper. The assistant mechanic stated that he gave the sheet of paper to the director but that he did not see what the director did with the paper. The director stated that he recorded the corrected readings on a new cylinder differential compression check form; however, company personnel did not locate the corrected form. The director stated that he did not conduct cylinder borescope inspections on cylinder Nos. 2 and 4 because the repeated compression checks yielded readings that were within acceptable limits. The Director of Maintenance stated that the company had removed and replaced an engine cylinder assembly about five or six times in the last 3 years. The director stated that, before applying torque to the cylinder studs, maintenance personnel coated the studs with an aluminum-copper-graphite, lithium-based antiseize compound manufactured by Permatex. TCM SB 96-7B specifies that clean 50-weight aviation-grade engine oil should be applied to the studs and through bolts before applying torque. Permatex does not recommend using antiseize compound in high-vibratory environments because such use could contribute to the loss of torque. 34 The Director of Maintenance stated that he would consider any reading below 58 psi to be too low and that low readings would require that the cylinder be rechecked. The director did not mention that the reading recorded for cylinder No. 3 was too low, even though he stated that it was “55.” Factual Information 15 Aircraft Accident Report 1.6.1.3 Time Between Overhauls TCM Service Information Letter 98-9A recommends that TSIO-520-VB engines have a time between overhaul (TBO) of 1,600 hours. Air Sunshine began operating its airplanes equipped with TSIO-520-VB engines in accordance with this recommendation. After Air Sunshine’s inspection program received FAA approval in early 1992,35 the company applied to the Fort Lauderdale FSDO for a 200-hour extension of its TBO per the procedures outlined in FAA Order 8300.10, Airworthiness Inspector’s Handbook.36 The FAA principal maintenance inspector (PMI) for Air Sunshine granted its request and allowed the company to increase its TBO by 200 hours. From late 1992 to late 1995, Air Sunshine applied for four additional TBO extensions (of 200 hours, 200 hours, 100 hours, and 100 hours) for a total TBO extension of 800 hours. The FAA granted approval for all of the requested extensions, which resulted in a TBO of 2,400 hours. According to FAA Order 8300.10, approval of TBO extensions is granted based on “satisfactory service experience and/or a teardown examination of at least one exhibit engine.” Neither the FAA nor Air Sunshine had retained the paperwork that related to the five requests for, and approvals of, the extensions of the company’s TBO for longer than the 2 years required by the FAA. However, Air Sunshine provided the Safety Board with four teardown reports prepared by Airmark Overhaul (which were submitted as support for the first four TBO extension requests) and one report prepared by TCM (which was submitted as support for the last request). These reports were dated July 16, 1992; November 17, 1992; March 20, 1994; January 20, 1995; and October 9, 1995. All of the teardowns conducted by Airmark and TCM were of TCM-rebuilt engines. After Air Sunshine received approval for the last 100-hour TBO extension, the company petitioned the Fort Lauderdale FSDO to change the company’s operations specifications to reflect the 2,400-hour TBO, and the Fort Lauderdale FSDO granted the request under the condition that the company’s airplane engines be rebuilt by TCM. In late August/early September 1999, after Air Sunshine transferred its operations certificate to the San Juan FSDO, the company petitioned the San Juan FSDO to remove from the company’s operations specifications the requirement that TCM rebuilt engines must be used. In a letter dated September 9, 1999, the FAA PMI for Air Sunshine stated that he would grant the company’s request provided it (1) monitored the performance of newly overhauled engines and reported any abnormal conditions to the San Juan FSDO,37 (2) used 35 Air Sunshine was required to have its own AAIP to receive FAA approval for TBO extensions. 36 FAA Order 8300.10 indicates that TBO extensions for reciprocating engines can be granted in increments of up to 200 hours. 37 A review of Air Sunshine and FAA records revealed that the company made no reports to the FAA between the date of this letter and the date of the accident in which the company reported any abnormal conditions of its overhauled engines. Factual Information 16 Aircraft Accident Report the approved overhaul facilities listed in its Maintenance Manual vendor list, 38 and (3) established standards for parts to be used during the overhaul process. The PMI added that, if the engines did not perform satisfactorily, the company’s operations specifications would be amended back to the original TBO of 1,600 flight hours.39 1.7 Meteorological Information The closest airport to the location of the airplane wreckage was Grand Bahamas International Airport (MYGF), Freeport, Bahamas, which was about 63.9 nautical miles from where the airplane was located. MYGF does not have an automated weather system. Weather observations are made by an on-site weather observer and are recorded in coordinated universal time. Eastern daylight time is 4 hours behind coordinated universal time. The 1900 meteorological aerodrome report (METAR) (1500 local time, which was about 30 minutes before the ditching) indicated that winds were 160° at 8 knots, visibility was 10 nautical miles, clouds were broken at 2,000 feet, the temperature was 88.5° F, the dew point was 74.1° F, and the altimeter setting was 30.09 inches of Hg. The 2000 METAR (1600 local time, which was about 30 minutes after the ditching) indicated that winds were 140° at 10 knots, visibility was 10 nautical miles, a few clouds were at 1,500 feet and were scattered at 2,000 feet, the temperature was 88.5° F, the dew point was 74.1° F, and the altimeter setting was 30.08 inches of Hg. 1.8 Aids to Navigation The distance measuring equipment on the MYAT VOR40 had been inoperative for several years. 1.9 Communications No communication problems were reported. 1.10 Airport Information MYAT was the destination airport for flight 527. The airplane was ditched about 7.35 nautical miles west-northwest of the airport. 38 After its operations specifications were amended, Air Sunshine started using Airmark Overhaul, a company on the FAA-approved vendor list, to overhaul its engines. 39 For information about postaccident changes to Air Sunshine’s operations specifications, see section 1.17.2.5. 40 VOR stands for very high frequency omnidirectional range. Factual Information 17 Aircraft Accident Report 1.11 Flight Recorders The accident airplane was not equipped with either a CVR or an FDR and was not required to be so equipped. 1.12 Wreckage and Impact Information 1.12.1 General The airplane was submerged in water for about 3 weeks after the accident. Underwater photographs taken before the airplane was recovered from the water showed that the window escape hatch adjacent to the pilot seat (1A) was open. The emergency escape hatch adjacent to seats 2B and 3B was found closed. The top and bottom portions of the main cabin door adjacent to seats 4A and 5A were found open. Impact damage was noted on the lower fuselage skin from the wing main spar forward, and damage was noted on the nose cone. The landing gear was found retracted. All of the airplane’s major components,41 except for the left aileron and the outboard section of the right elevator and balance weight, were recovered attached to the airplane. The separated sections were not recovered. The rudder trim tab actuator was found positioned between 5° and 10° trailing edge tab right; the elevator trim tab actuator was found positioned at 15° trailing edge tab down. The left flap was found extended about 15°, and the cowl flap was nearly closed. The right flap was found extended about 15°, and the cowl flap was open. An oil sheen was noted on the exterior surface of the right engine upper cowling, from the louvers aft to the trailing edge of the wing; on the interior surface of the upper cowling; and on the upper and lower exterior surfaces of the horizontal stabilizer. The left fuel selector valve handle in the cockpit was found positioned to the left main fuel tank; the right fuel selector valve handle was missing; therefore, its position could not be determined. The emergency crossfeed/shutoff valve handle was found positioned to the crossfeed position. The left and right auxiliary fuel pump switches were found in the off position. The left and right cowl flap controls were found out (closed) and in (open), respectively. Both the flap selector and flap position indicator were found at about 15° flaps extended,42 and the landing gear selector handle was found in the retracted position. The elevator trim indicator was found positioned to full nose up. The aileron trim indicator was found positioned slight left wing down. The rudder trim indicator was found positioned nose left. 41 42 A major component is necessary for an airplane to sustain flight. During postaccident interviews, the pilot stated that he did not extend the flaps during the flight. The pilot stated that he would normally extend the flaps when he was about 3 miles from an airport. When he was asked how the flaps became extended to 15°, the pilot replied that after the ditching, some of the passengers crawled over him and that one of them might have hit the switch that extended the flaps. He stated that the flaps were extended electrically and that he had left the power on after the ditching. Factual Information 18 Aircraft Accident Report All seats were found attached to the floor and were undamaged. All lapbelts were present and were found to operate normally. The seatback stowage pockets for seats 2A and 2B did not contain safety briefing cards;43 all of the other stowage pockets contained briefing cards. Six packaged PFDs were found in the airplane. One PFD was found forward of the pilot seat, and one PFD was found forwa