NTSB Identification: FTW95IA022.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Incident occurred Sunday, October 16, 1994 in NACOGDOCHES, TX
Probable Cause Approval Date: 08/21/1995
Aircraft: CANADAIR CL 600, registration: N600RE
Injuries: 4 Uninjured.

NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.

DURING FLIGHT AT FL370, THE AIRPLANE ENTERED A CLOUD LAYER AND ENCOUNTERED TURBULENCE. A DESCENT WAS MADE TO FL330. AS POWER WAS BEING APPLIED FOR LEVEL OFF AT FL330, THE N1 INDICATION DID NOT RESPOND. AT FL310 THE #1 ENGINE FLAMED OUT. WEATHER INCLUDED ICE CRYSTALS, THUNDERSTORM OUTFLOW, AND TURBULENCE. DURING AN ATTEMPTED CROSS BLEED AIR START, THE #2 ENGINE FLAMED OUT. WITH THE AIR DRIVEN GENERATOR (ADG) DEPLOYED, THE CREW WAS SUCCESSFUL WITH AN APU ASSISTED START. BOTH ENGINES WERE STABILIZED BY 5000 FEET, AND THE FLIGHT LANDED SAFELY. INTERVIEWS AND INFORMATION FROM THE CVR REVEALED THAT THE CREW DID NOT CALL FOR THE EMERGENCY CHECKLIST AND THAT THEY LACKED KNOWLEDGE OF THE AIRPLANE SYSTEMS. AS THE CREW RECOGNIZED THE INITIAL POWER LOSS, THE CAPTAIN ASKED THE FIRST OFFICER IF HE HAD TURNED ON ENGINE ANTI-ICE. HE REPLIED THAT HE HAD NOT. THE CREW HAD NOT ATTENDED A FORMAL TRAINING COURSE FOR THE CL 600. THE CAPTAIN AND COPILOT RECEIVED TYPE RATINGS FROM A DESIGNATED PILOT EXAMINER (DPE) IN MAY AND MARCH 1994, RESPECTIVELY. TESTS OF THE FUEL CONTROL UNITS REVEALED DISCREPANCIES IN THE START AND ACCELERATION SCHEDULES; HOWEVER, NO DISCREPANCIES WERE FOUND THAT WOULD HAVE CONTRIBUTED TO THE FLAMEOUTS.

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

THE FLIGHT CREW'S IMPROPER USE OF THE ANTI-ICE SYSTEM, WHICH RESULTED IN ENGINE ICE, SUBSEQUENT ICE INGESTION, AND ENGINE FLAMEOUT. FACTORS RELATED TO THE ACCIDENT WERE: FAILURE OF THE FLIGHT CREW TO FOLLOW THE CHECKLIST PROCEDURES AFTER FLIGHT INTO ADVERSE WEATHER CONDITIONS, AND THE AIRCREW'S LACK OF FAMILIARITY WITH THE AIRCRAFT REGARDING FLIGHT IN ICING C0NDITIONS.

Full narrative available

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