August 13, 2004
NTSB Number: AAR-06-03
NTIS Number: PB2006-910403
Adopted May 2, 2006
On August 13, 2004, about 0049 eastern daylight time, Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a cargo flight for DHL Express from Memphis International Airport, Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
The National Transportation Safety Board determines that the probable cause of this accident was fuel starvation resulting from the captain's decision not to follow approved fuel crossfeed procedures. Contributing to the accident were the captain's inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist. Further contributing to the accident was the flight crew's failure to monitor the fuel gauges and to recognize that the airplane's changing handling characteristics were caused by a fuel imbalance.
The safety issues discussed in this report include flight crew performance, fuel crossfeed operations, operating with different fuel boost pump output pressure settings, and cockpit voice recorder power source reliability. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. A safety recommendation concerning operating with different fuel boost pump output pressure settings is addressed to Transport Canada.
As a result of its investigation of the August 13, 2004, Air Tahoma, Inc., flight 185 accident, the National Transportation Safety Board makes the following recommendations:
To the Federal Aviation Administration:
Issue a flight standards information bulletin to all principal operations inspectors of Convair 580 operators that familiarizes operators with the circumstances of the Air Tahoma flight 185 accident, including the importance of closing the fuel tank shutoff valve for the tank not being used during fuel crossfeed operations. (A-06-39)
Require Convair 580 operators to set the left and right fuel boost pump output pressure settings on their airplanes to the same setting. (A-06-40)
To Transport Canada:
Require Convair 580 operators to set the left and right fuel boost pump output pressure settings on their airplanes to the same setting. (A-06-41)
The Safety Board reiterates the following recommendation to the Federal Aviation Administration:
Require retrofit after January 1, 2005, of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR that (a) meets Technical Standard Order (TSO) C123a, (b) is capable of recording the last 2 hours of audio, and (c) is fitted with an independent power source that is located with the digital CVR and that automatically engages and provides 10 minutes of operation whenever aircraft power to the recorder ceases, either by normal shutdown or by a loss of power to the bus. (A-99-16)