NTSB Factual Report

HISTORY OF FLIGHT

On September 1, 2008, about 1810 Pacific daylight time, N4235T, a Lockheed P2V-7/SP-2H airplane, was destroyed after impacting terrain following a loss of power and loss of control about 2 miles northwest of the Reno/Stead (4SD) Airport, Reno, Nevada. The airplane, using the call sign Tanker 09, was registered to Neptune Aviation Services Inc., of Missoula, Montana, and operated by the California Department of Forestry and Fire Protection (CAL FIRE). The airline transport licensed captain, who occupied the left crew seat, the airline transport licensed co-pilot, who occupied the right crew seat, and the flight mechanic, who occupied the cockpit jumpseat, were killed. Visual meteorological conditions prevailed for the Public Use air drop flight, which was being operated in accordance with Title 14 Code of Federal Regulations (CFR) Part 137, and a company flight plan was filed and activated. The flight was originating at the time of the accident.

According to Neptune Aviation Services' records, the accident flight crew had flown 1 firefighting support mission on the morning of the accident. The purpose of the accident flight was to support the Smitty fire, which was located about 85 nautical miles south of 4SD.

According to records provided by the United States Department of Agriculture (USDA) Forest Service, at 1730 the Sierra Front Interagency Dispatch Center (SFIDC) submitted an initial attack resource order to the Reno/Stead Air Attack Base for two air tankers to support the Smitty Fire. At 1735, the resource order was received and the crew of Tanker 09 was notified of the dispatch. At 1743, Tanker 09 was loaded with 2,070 gallons of fire retardant. At 1755, Tanker 09 registered in micro motion data as "completed loading." At 1758, the captain radioed ramp instructions to not cancel their hotel rooms. They would be returning to Reno/Stead.

In an interview conducted by the NTSB investigator-in-charge (IIC), the accident airplane's regularly assigned crew chief reported that on the morning of the accident he arrived at the tanker base at about 0900. The crew chief further reported that upon his arrival he did a walk-around, performed his checks of the airplane and noted no anomalies. The crew chief stated that the captain fueled the right wing, the co-pilot fueled the left wing, and after the co-pilot completed fueling he did his walk-around inspection of the airplane, with no anomalies noted. The crew chief reported that after all crew members were aboard, the radial engines were started followed by the jet engines being started; again, no anomalies were noted. After takeoff at about 1000, the airplane departed to the south, proceeded to the retardant drop area and made two drops before returning to the air attack base. The crew chief stated that after landing and shutting down, no fuel was added; his post-flight walk-around inspection did not reveal any anomalies with the airplane. He continued by stating that the crew then had lunch at the tanker base, and after lunch he looked over the accident airplane again, and again no anomalies were noted. The crew chief stated that about 1730 the accident crew received a dispatch notice, after which he and the accident flight mechanic preflighted the airplane; again, no anomalies were noted. The crew chief revealed that the accident flight mechanic had requested to take the flight, which the captain authorized. The crew chief stated that while standing at the rear and to the left of the airplane, he observed the radial engines being started, the magnetos being checked, and the jet engines started; no anomalies were noted. The crew chief reported that he witnessed the accident airplane on the runway ready for takeoff, again viewing it from the left side, and again said he didn't observe any anomalies. He reported that he watched the airplane take off, observed the landing gear retract and lock in the wheel wells, "… and when the airplane was approximately 200 feet I saw a ball of fire, with flames coming out of the left jet. It was in a 10 to 15 degree left bank." The crew chief stated that he made a call to the tanker base to inform the flight crew that they had a left jet fire. The crew chief stated that after the airplane went out of view, the next thing he saw was a ball of fire.

At 1801:32.8, after both radial engines had been started, the Cockpit Voice Recorder (CVR) indicated that the captain briefed the co-pilot where they were going on the map – near Reno.

At 1804:04.6, the CVR indicated the captain said, "Go ahead and start your engines."

From 1805:06.7 to 1806:28.0, the captain and co-pilot proceed through the challenge and response Before Takeoff checklist.

At 1805:44.3, the CVR recorded the co-pilot say, "Briefing."

At 1805:45.5, the CVR indicated the captain said, "Okay, this will be a VFR departure off of runway three two. Same numbers, same calls. Ah, if we get into the air we enter a left downwind, come back around for three two. I don't want to pack the load. Any questions?"

At 1806:09.3, the CVR recorded the captain tell the co-pilot, "Actually, this will be your takeoff."

At 1806:14.4, the CVR indicated the co-pilot said, "Same briefing (sound of laugh)."

At 18:07:05.8, the CVR recorded the sound of increasing engine speed.

At 1807:16.5, the CVR indicated the co-pilot said, "Got rudder control."

At 1807:27.7, the CVR indicated the captain said, "Eighty, cross checked."

At 1807:38.9, the CVR indicated the captain said, "One oh eight, rotate."

At 1807:43.9, the CVR indicated the co-pilot said, "Positive rate."

At 1807:55.5, the CVR indicated the co-pilot said, "METO (Maximum Except Take Off) power."

At 1808:00.2, the CVR indicated the sound of decreasing engine speed.

At 1808:05.4, the CVR indicated the co-pilot said "Whoa," followed by a sound of heavy breathing.

At 1808:10.5, the CVR indicated the captain said, "We got a fire over here. A big ol fire."

At 1808:15.2, the CVR indicated the co-pilot said, "I'm holding full right aileron."

At 1808:28.8, the CVR indicated the captain made a sound of heavy breathing..

At 1808:31.0, the CVR indicated the captain made a sound of heavy breathing.

At 1808:32.3, the CVR indicated the sound of impact. End of recording.

The recorded data revealed that during the emergency the flight crew did not perform the engine fire emergency procedure for the jet engine that failed, nor did the captain attempt to assume command of the airplane during the emergency.

The wreckage site was located at a measured distance of 1.2 nautical miles from the departure end of Runway 32, on a measured magnetic heading of 289 degrees. The impact heading was on a measured magnetic bearing of 260 degrees, and the airplane came to rest on a measured magnetic heading of 250 degrees.

Three air attack base personnel submitted witness statements to the NTSB IIC:

Witness #1, the air attack base ramp manger, reported that as he watched Tanker 09 proceed down the runway on its takeoff roll he was talking with one of Tanker 09's mechanics who said that the left side gas jet was on fire as the airplane was lifting off. The ramp manager further stated that at this point he tried calling the crew of Tanker 09 to inform them that they had an engine fire, but there was no response. The ramp manager reported that he observed the wing had become fully engulfed in flames, followed by the fire increasing before the airplane banked to the left and crashed "in a ball of flames."

Witness #2, the assistant air attack base manager, reported that prior to Tanker 09's takeoff roll, he issued a "roll time" of 1806, then observed the flight crew running up the radials and the turbines prior to the takeoff roll. The assistant base manger said that during the airplane's takeoff roll he observed "an unusually bright orange glow coming from the left wing." The assistant base manager revealed that when he observed the airplane begin a left turn, the glow of the fire increased. The assistant base manager reported, "I watched as the aircraft slowly rolled left about 45 degrees of bank, about 200 to 300 feet above ground level (agl). The fire grew explosively and engulfed the left wing. The aircraft attitude at 45 degrees of bank appeared to be a sideslip, like the right rudder was given, and then continued to roll left past 60 degrees [of bank] as the aircraft yawed back left and impacted the ground left wing first, slightly nose down."

Witness #3, the air attack base manager stated that on the day of the accident he was functioning as the Parking Tender for Tanker 09, and that he marshaled the airplane out on the accident flight. The base manager reported that after marshaling the airplane out, he went upstairs to the dispatch office and heard Tanker 09 call "rolling," and at the same time "I heard the jet assist and the plane rolling down Runway 32." The base manager stated that he subsequently heard another ground crewman yell, "Oh no. Oh no." The base manager stated, "I could see the left jet engine was on fire. It gave the appearance of a meteor with a tail of fire trailing the left side. It also appeared that the whole left wing was ablaze and the plane was turning left before impact. From my vantage point it seemed the aircraft was between 300 to 500 feet agl (above ground level) before it started losing altitude."

Additionally, four witnesses who were located outside of the airport property submitted witness statements to the NTSB IIC:

Witness # 1 reported observing the airplane depart Runway 32 with its left wing on fire. The witness further reported hearing two "exploding noises," followed by seeing the airplane in a left turn before being out of control. The witness reported observing the airplane flipping upside down in a nose down attitude and going through power lines before impacting the ground.

Witness #2 reported hearing a "small explosion" as the airplane took off and observed its left engine on fire. The witness stated that it appeared the airplane "…struggled to level out and climb, then it turned over and hit the ground."

Witness #3 reported that while exiting an interstate highway which borders the airport, "…my wife and I noticed an orange light over the airfield. The light got larger and we realized we were watching an aircraft going down. After about 5 seconds the aircraft impacted the ground with a large fireball."

Witness #4, a first responder to the accident site, reported that while observing the airplane proceeding to the north, "I heard the aircraft engine make a loud backfire." The witness stated that the airplane then went behind some trees and out of sight, and then she heard a loud explosion, followed by observing a large plume of black smoke.

PERSONNEL INFORMATION

The Captain

The captain, age 61, held an airline transport pilot certificate with the ratings and limitations of airplane multiengine land, commercial privileges for airplane single-engine land, and type ratings for the CE-500, DC-3, DC-3TP and the L-P2V. He obtained his L-P2V type rating on August 23, 1984. Additionally, he held flight instructor and airframe and powerplant mechanic certificates. His most recent FAA first-class medical certificate was issued on January 25, 2008, with no limitations or waivers.

According to Neptune Aviation Services' records, the captain had accumulated 9,520 total flying hours, of which 2,860 were in the L-P2V. He had flown 5, 55, and 118 hours in the past 24 hours, 30 days, and 90 days respectively. The captain's most recent FAR 61.58 pilot-in-command proficiency check was completed on February 21, 2008.

The captain completed Crew Resource Management Training on February 8, 2008, and on February 22, 2008, he was authorized to act as a FAA pilot proficiency examiner on P2V 5 & 7 series airplanes. On February 28, 2008, the captain completed Neptune Aviation Ground Training, and on March 18, 2008, he was designated as a company initial attack training pilot. The captain's most recent Forest Service Airplane Pilot Qualification and Approval Record was dated April 10, 2008.

The captain's original date of hire with Neptune Aviation Services was July 10, 1998. He was employed as a United States Forest Service Pilot from 1978 to 1998, and again from April 2004 until November 2007. The captain returned to Neptune Aviation Services to assume the role as company chief pilot on November 1, 2007.

The Co-pilot

The co-pilot, age 41, held an airline transport pilot certificate with the ratings and limitations of airplane multiengine land, commercial privileges for airplane single-engine land, and a type rating for the L-P2V. He obtained his L-P2V type rating on April 29, 2006. Additionally, he held flight instructor and airframe and powerplant mechanic certificates. His most recent FAA first-class medical certificate was issued on December 26, 2007, with no limitations or waivers.

According to Neptune Aviation Services' records, the co-pilot had accumulated 2,812 total flight hours, of which 324 were in the L-2PV. He had flown 5, 55, and 121 hours in the past 24 hours, 30 days, and 90 days respectively. His most recent FAR 61.55 second-in-command qualification check was completed on March 3, 2008. He completed Crew Resource Management Training on February 14, 2008, and Neptune Aviation Ground Training on February 18, 2008. His most recent Forest Service Airplane Pilot Qualification and Approval Record was dated April 9, 2008.

The co-pilot's date of hire with Neptune Aviation Services was July 1, 2002.

The Flight Mechanic

According to Neptune Aviation Services records, the flight mechanic, age 25, was hired on May 1, 2008. The flight mechanic held airframe and powerplant mechanic certificates and a private pilot certificate with an airplane single-engine land rating. Company personnel reported that this was the flight mechanic's first operational flight on the L-P2V.

AIRCRAFT INFORMATION

N4235T, serial number 150282, was manufactured by the Lockheed Aircraft Corporation in 1962. A mid-wing, 4-engine airplane, it was originally developed by the United States Navy as an anti-submarine warfare airplane.

The airplane is powered by two radial, 18 cylinder, aircooled, Curtiss Wright R3350-32WA engines, rated at 2,800 horsepower, driving Hamilton Standard hydromatic propellers, and two auxiliary Westinghouse J34-WE-36 turbojet engines, each rated at 1,500 pounds of thrust. The turbojet engines were installed to improve takeoff characteristics at increased gross weights and to furnish additional power when required.

The airplane's left outboard engine (position #1) was a Westinghouse J34-WE-36 turbojet engine, serial number 211235. Total time on the engine was 703.4 hours, 384.4 hours since overhaul, and 64 hours since its last inspection.

The airplane's left inboard engine (position #2) was a Curtiss Wright R3350-32WA radial engine, serial number W549601. Total time on the engine was 5,000 hours, 49 hours since overhaul, and 64 hours since its last inspection.

The airplane's right inboard engine (#3 position) was a Curtiss Wright R3350-32WA radial engine, serial number W573623. Total time on the engine was 4,587 hours, 560 hours since overhaul, and 64 hours since its last inspection.

The airplane's right outboard engine (position #4) was a Westinghouse J34-WE-36 turbojet engine, serial number 211233. Total time on the engine was 441 hours, 126 hours since overhaul, and 64 hours since its last inspection.

Neptune Aviation Services' Inspection Program

Neptune Aviation Services' P2V-5's and P2V-7's are maintained under an Approved Aircraft Inspection Program (AAIP) as set forth by the Federal Aviation Administration [Title 14 CFR Part 91.409 (f) (4)]. Incorporated in the AAIP program is a Phase D inspection, which contains a tracking/signoff sheet that lists each routine work card that is included in the inspection. The work cards themselves define the specific tasks to be completed.

Phase D inspections are required within 12 calendar months of the previous Phase D inspection, and are normally performed in conjunction with a Phase B and Phase C inspections during the off season while the airplanes are back at their hom

NTSB Probable Cause

The failure of the flight crew to maintain airspeed above in-flight minimum control speed (Vmca) after losing power in the left jet engine during initial climb after takeoff. Contributing to the accident was the crew's inadequate cockpit resource management procedures, the failure of the captain to assume command of the airplane during the emergency, the flight crew's failure to carry out the jet engine fire emergency procedure, and the failure of the crew to jettison the retardant load.