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Safety Recommendation Details

Safety Recommendation A-06-039
Details
Synopsis: On August 13, 3004, about 0049 eastern daylight time, Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnatimorthern Kentucky International Airport, 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 Regzllations Part 121 as a cargo flight for DHL exrpess from Memphis International Airport. Memphis, Tennessee, to Covington. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Issue a flight standards illformation 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 iinportancc of closing the fuel tank shutoff valve for the tank not being used during fuel crossfeed operations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Florence, KY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA04MA068
Accident Reports: Crash During Approach to Landing, Air Tahoma, Inc., Flight 185, Convair 580, N586P
Report #: AAR-06-03
Accident Date: 8/13/2004
Issue Date: 5/17/2006
Date Closed: 6/15/2009
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/15/2009
Response: This recommendation was issued to address the NTSB’s concern that, because Convair 580 pilots may mistakenly believe that the fuel tank shutoff valves have a tendency to fail, these pilots might avoid closing the fuel tank shutoff valve during fuel crossfeed operations. Leaving the valve open during these operations could allow fuel to transfer and cause either structural damage or fuel overflow. In response to this recommendation, on July 27, 2006, the FAA issued SAFO 06011, Convair 580 Fuel Crossfeed, and Potential for Fuel Starvation. The SAFO emphasized the importance of Convair 580 pilots’ following proper procedures when transferring fuel in-flight. When the NTSB reviewed SAFO 06011, the NTSB was concerned because the SAFO did not emphasize the importance of closing the fuel valve of the tank not in use. During the investigation of the Air Tahoma accident, the accident pilot revealed in postaccident interviews that he had intentionally kept the fuel valve open because he thought that Convair fuel tank shutoff valves tended to fail after being closed, preventing the use of the fuel in the closed tank. This failure to close the fuel valve was a critical factor in the cause of the accident. On September 4, 2007, the NTSB asked for the SAFO to be revised to address the specific concerns described in the NTSB’s September 4, 2007, letter. Pending that revision and reissuance of the SAFO, Safety Recommendation A-06-39 was classified Open Acceptable Response. SAFO 08023 is the revision to SAFO 06011 that the NTSB requested. Our review of the new SAFO revealed that it fully addresses the concerns that we described in our letter and that the new SAFO is fully responsive to Safety Recommendation A-06-39; consequently, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 9/4/2007
Response: This recommendation was issued in part because the Safety Board was concerned that, because Convair 580 pilots may mistakenly believe that the fuel tank shutoff valves have a tendency to fail, these pilots might avoid closing the fuel tank shutoff valve during fuel crossfeed operations. Leaving the valve open during these operations could allow fuel to transfer and cause either structural damage or fuel overflow. The Board notes that in response to the recommendation, on July 27, 2006, the FAA issued Safety Alert for Operators (SAFO) 06-011, Convair 580 fuel crossfeed, and potential for fuel starvation. The SAFO emphasizes the importance of Convair 580 pilots’ following the proper procedures when transferring fuel in-flight. However, review of SAFO 06-011 revealed that it does not emphasize the importance of closing the fuel valve for the fuel tank not being used, which was specifically noted in the safety recommendation as important information. During the investigation of the Air Tahoma accident, the accident pilot revealed in post-accident interviews that he had intentionally kept the fuel valve open because he thought that Convair fuel tank shut-off valves tended to fail after being closed, preventing the use of the fuel in the closed tank. The Board noted that failure to close the fuel valve was a critical factor resulting in the accident; therefore, this information should be disseminated to principle operations inspectors (POI) for review with Convair 580 operators. Because of the Safety Board’s concerns about the SAFO, on October 11, 2006, representatives of the FAA and the Board held a teleconference to discuss these issues. During this teleconference, Board staff discussed the problem detailed above. Staff also discussed its concerns that, although the SAFO mentions that fuel transfer on the Convair 580 may cause structural failure or overflow of fuel through the vent system, it does not state that failure to close the fuel tank shutoff valve during fuel crossfeed operations may result in a fuel imbalance, creating unusual airplane handling characteristics, and possible fuel exhaustion (the causes of the Air Tahoma accident). Because of these concerns, Safety Board staff asked for the SAFO to be revised and reissued. The FAA agreed to survey Convair 580 operators to determine whether, as a result of the SAFO, the operators had emphasized the following specific points: 1.the importance of closing the appropriate fuel tank shut off valve during crossfeeds 2.the fact that failure to close the fuel tank shutoff valve during fuel crossfeed operations could cause a fuel imbalance, creating aircraft handling problems, and possible fuel starvation 3.the fact that Convair 580 pilots routinely do not close the required fuel shutoff valve due to concerns that the closed valve may fail In response to a question from the Safety Board on the results of the survey, the FAA reported that the SAFO had been issued to all POIs of Convair 580 operators, but the FAA did not know whether those POIs had reviewed the information with their operators. Although the Board appreciates the quick response of the FAA in issuing the SAFO, the document does not fully address the intent of this recommendation. Therefore, we request that the FAA revise the SAFO to address the specific concerns described in this letter and discussed on October 11, 2006, and to reissue it to Convair 580 operators and POIs. Pending revision and reissuance of the SAFO, Safety Recommendation A-06-39 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/1/2006
Response: Letter Mail Controlled 8/15/2006 8:45:38 AM MC# 2060398: Marion C. Blakey, Administrator, FAA, 8/1/06 The Federal Aviation Administration found five operators using the Convair 580, Air Tahoma, Inc., being one of them. There are a total of 17 Convair 580s being operated in accordance with 14 CFR Parts 121,125, and 129. There were none found being operated in accordance with Part 91. The FAA is drafting a Safety Alert for Operators (SAFO) which will address this recommendation. The SAFO will be available by September 30, 2006. The Convair 580 operators will be made aware of the August 13,2004, accident involving Air Tahoma, Inc. Each SAFO is available to our field offices and the public on a Web site at http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo/. We have had good response to SAFO's issued so far and find this to be the best way to reach the community that operates the Convair 580. I believe that the FAA has satisfactorily