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C404, Kulusuk Greenland, 2002

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Summary
On 1 August 2002, a Cessna 404, en-route at FL130 over Greenland, experienced sudden power loss on both engines, probably as a result of ice in the induction systems, leading to loss of control. The crew regained control at 3000 feet.
Event Details
When August 2002
Actual or Potential
Event Type
Human Factors, Loss of Control, Weather
Day/Night Day
Flight Conditions IMC
Flight Details
Aircraft CESSNA 404 Titan
Operator Not Recorded
Type of Flight Public Transport (Passenger)
Origin Reykjavik Airport
Intended Destination Nuuk Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Cruise
ENR
Location En-Route
Origin Reykjavik Airport
Destination Nuuk Airport
Location
Approx. 30NM west of Kulusuk
Loading map...


HF
Tag(s) Inappropriate crew response (automatics),
Manual Handling,
Procedural non compliance
LOC
Tag(s) Loss of Engine Power,
Flight Control Error"Flight Control Error" is not in the list (Airframe Structural Failure, Significant Systems or Systems Control Failure, Degraded flight instrument display, Uncommanded AP disconnect, AP Status Awareness, Non-normal FBW flight control status, Loss of Engine Power, Flight Management Error, Environmental Factors, Bird or Animal Strike, ...) of allowed values for the "LOC" property.
WX
Tag(s) In Flight Icing - Piston Engine
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Loss of Control - Engine Inlet Icing

Description

On 1 August 2002, a Cessna 404, en-route at FL130 over Greenland, experienced sudden power loss on both engines, probably as a result of ice in the induction systems, leading to loss of control. The crew regained control at 3000 feet914.4 m
.

Synopsis

The following is an extract from the official Danish Investigation Report:

During climb to and en-route at FL130, the aircraft was most likely exposed to icing conditions. The flight crew lost control of the aircraft and it descended uncontrollably. At approximately 3000 feet, the flight crew regained control of the aircraft…The incident occurred in daylight and under instrument meteorological conditions (IMC).

The report's findings include:

Flight Planning

  • The planned and filed FL was below the minimum safe FL across the ice cap.
  • The operational flight plan did not fulfil the requirements of JAR-OPS 1.
  • The single engine service ceiling was most probably below the minimum safe FL across the ice cap.

Mass & balance

  • The mass and balance documentation was inconsistent and incorrect.
  • The passenger mass data in the mass and balance report was not in accordance with JAR-OPS 1 and the Operations Manual.
  • With reference to standard masses, the actual take off mass was 960 lbs above the maximum allowable take off mass.
  • Mass data in the mass and balance computer programme were incorrect.

Communications

  • The aircraft was not equipped with HF radio communication equipment as required in the Greenlandic AIP.

Airmanship

  • During climb to and cruise at FL130, the aircraft was most likely exposed to icing conditions.
  • Partial loss of power on both engines was probably caused by ice in the induction systems of the engines.
  • The flight crew did not perform the emergency checklist for air inlet icing.
  • The aircraft was not able to maintain altitude.
  • The IAS very likely approached the actual stall speed.
  • The partial loss of power on both engines probably resulted in either an asymmetric stall or a pilot induced Dutch roll.
  • At 3000 feet msl with a positive OAT, the flight crew regained control of the aircraft.

In summary

…The flight crew planned and performed a flight into an arctic area with forecasted risk of moderate icing conditions. The icing conditions led to a sudden and unpredictable partial power loss on both engines. The unpredictable partial loss of engine power and the lack of appropriate emergency checklist actions resulted in an uncontrollable descent.

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