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Cross Feed

The Office of Aviation Safety investigated the August 13, 2004 crash of Air Tahoma Flight 185, a Convair 580 that crashed near Covington, Kentucky. The investigation found that the captain was distracted doing weight and balance calculations during the flight. He improperly transferred fuel between tanks using the crossfeed system without following procedures. The flight crew missed opportunities to address issues with the airplane's handling in the last 9 minutes of flight. This led to low fuel levels in both tanks and a dual engine flameout. Significant findings included the captain's distraction, improper fuel crossfeed operation, and missed opportunities by the flight crew to troubleshoot problems.

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39 views

Cross Feed

The Office of Aviation Safety investigated the August 13, 2004 crash of Air Tahoma Flight 185, a Convair 580 that crashed near Covington, Kentucky. The investigation found that the captain was distracted doing weight and balance calculations during the flight. He improperly transferred fuel between tanks using the crossfeed system without following procedures. The flight crew missed opportunities to address issues with the airplane's handling in the last 9 minutes of flight. This led to low fuel levels in both tanks and a dual engine flameout. Significant findings included the captain's distraction, improper fuel crossfeed operation, and missed opportunities by the flight crew to troubleshoot problems.

Uploaded by

Dreetn Dree
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Office of Aviation Safety

Air Tahoma Flight 185


Convair 580
August 13, 2004
Covington, Kentucky
Non-Contributing Factors

• No preexisting failures
• No evidence of fatigue
• Sufficient fuel on board
Accident Summary
• Captain was distracted
– Weight and balance during flight
• Crossfeed operations
– Proper procedures not followed
– Fuel transferred between tanks
• Flight crew missed opportunities
• Dual engine flameout
Main Investigative Areas

• Captain’s weight and balance calculations


• Fuel crossfeed operation
• Monitoring fuel quantity
• Dual engine flameout
Weight and Balance

• No load manifest left at Memphis


• Weight and balance computer inoperative
• Paperwork – outside limits
• Used “general experience”
Distraction

• Captain completing paperwork in flight


• 50 minutes after takeoff
– started crossfeed operations
• Captain did not follow procedures
Office of Aviation Safety
Convair 580 Limitations

• Fuel transfer prohibited


• AFM & cockpit placard
Fuel transfer from tank to tank is
prohibited. When operating with the
crossfeed system, turn off fuel valve for
tank not being used.
• No history of valve failures
Missed Opportunities

• Airplane handling characteristics


• Over the last 9 minutes
• First officer
– “yoke feels funny”
– “feels like I need a lot of force”
– “what in the world is going on with this plane”
Missed Opportunities

• Captain did not


– Check fuel quantity
– Initiate troubleshooting
– Assess the handling qualities
• Captain
– “we’ll do a full control check on
the ground”
Missed Opportunities

• Captain
– Started in-range checklist at 3,200 feet
– Found open crossfeed
– 30 seconds before dual engine flameout
• Air Tahoma Procedures
– Start in-range checklist at 12,000 feet
Office of Aviation Safety
Significant Findings

• Captain was distracted during flight


• Improper fuel crossfeed
• Flight crew missed opportunities
• Different fuel pump pressures
NTSB Staff
• Tom Jacky • Abdullah Kakar
• David Tew • Kristen Sears
• Malcolm Brenner • Paul Sledzik
• Clint Crookshanks • Brian Fiffick
• Anna Cushman • Paul Schlamm
• Greg Smith • Christy Spangler
• Pierre Scarfo • Gina John
• Sonia Louallen
Parties and Accredited Rep
PARTIES
• Federal Aviation Administration
• Air Tahoma
• Rolls-Royce

ACCREDITED REPRESENTATIVE
• Transportation Safety Board of Canada
– Kelowna Flightcraft Ltd.
Office of Aviation Safety Workload

• 8 major investigations
• 5 major reports
• 385 regional investigation launches
• 21 foreign investigation launches
• 88 safety recommendations

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