NTSB/AAB-02/05 

E PLURIBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N

National Transportation Safety Board 

Washington, D.C. 20594 

Aircraft Accident Brief 

Accident No.: DCA00MA052 

Operator or Flight Number: Executive Airlines 

Aircraft and Registration: British Aerospace J-3101, N16EJ 

Location: Bear Creek Township, Pennsylvania 

Date: May 21, 2000 

HISTORY OF FLIGHT 

On May 21, 2000, about 1128 eastern daylight time (EDT),1 a British Aerospace 

Jetstream 3101, N16EJ, operated by East Coast Aviation Services (doing business as Executive 

Airlines) crashed about 11 miles south of Wilkes-Barre/Scranton International Airport (AVP), 

Wilkes-Barre, Pennsylvania. The airplane was destroyed by impact and a postcrash fire, and 

17 passengers and two flight crewmembers were killed. The flight was being conducted under 

14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight for Caesarís 

Palace Casino in Atlantic City, New Jersey. An instrument flight rules (IFR) flight plan had been 

filed for the flight from Atlantic City International Airport (ACY) to AVP. 

The captain checked in for duty about 0800 at Republic Airport (FRG) in Farmingdale, 

New York, on the day of the accident. The airplane was originally scheduled to depart FRG at 

0900 for ACY and to remain in ACY until 1900, when it was scheduled to return to FRG. While 

the pilots were conducting preflight inspections, they received a telephone call from Executive 

Airlinesí owner and chief executive officer (CEO) advising them that they had been assigned an 

additional flight from ACY to AVP with a return flight to ACY later in the day, instead of the 

scheduled break in ACY. 

Fuel records at FRG indicated that 90 gallons of fuel were added to the accident 

airplaneís tanks before departure to ACY. According to Federal Aviation Administration (FAA) 

air traffic control (ATC) records, the flight departed at 0921 (with 12 passengers on board) and 

arrived in ACY at 0949. According to passenger statements, the captain was the pilot flying from 

FRG to ACY.2

 After arrival in ACY, the flight crew checked the weather for AVP and filed an 

IFR flight plan. Fuel facility records at ACY indicated that no additional fuel was added. The 

 1

 Unless otherwise indicated, all times are EDT, based on a 24-hour clock. The accident time is approximate, 

based on air traffic control (ATC) information. 2

 According to company practices, pilots alternated pilot flying duties each flight leg. Representatives of 

Executive Airlines who were familiar with both pilots reviewed the ATC recordings from AVP approach and tower 

facilities and identified the captain as the pilot speaking with ATC in all radio transmissions. Based on company 

policy, it is likely that the first officer was the pilot flying on the flight to AVP. 
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NTSB/AAB-02/05 

accident flight to AVP, which departed ACY about 1030, had been chartered by Caesarís Palace. 

According to ATC records, the flight to AVP was never cleared to fly above 5,000 feet mean sea 

level (msl).3

According to ATC transcripts,4

 the pilots first contacted AVP approach controllers at 

1057 and were vectored for an instrument landing system (ILS)5

 approach to runway 4. The flight 

was cleared for approach at 1102:07, and the approach controller advised the pilots that they 

were 5 nautical miles (nm) from Crystal Lake, which is the initial approach fix (IAF) for the ILS 

approach to runway 4.6

 The pilots were told to maintain 4,000 feet until established on the 

localizer. At 1104:16, the approach controller advised that a ìprevious landingÖaircraft picked 

up the airport at minimums [decision altitude].î7 The pilots were instructed to contact the AVP 

local (tower) controller at 1105:09, which they did 3 seconds later. The airplane then descended 

to about 2,200 feet, flew level at 2,200 feet for about 20 seconds, and began to climb again about 

2.2 nm from the runway threshold when a missed approach was executed (see the Airplane 

Performance section for more information). 

 At 1107:26 the captain reported executing the missed approach but provided no 

explanation to air traffic controllers.8 The tower controller informed the North Radar approach 

controllers of the missed approach and then instructed the accident flight crew to fly runway 

heading, climb to 4,000 feet, and contact approach control on frequency 124.5 (the procedure 

published on the approach chart). The pilots reestablished contact with the approach controllers 

at 1108:04 as they climbed through 3,500 feet to 4,000 feet and requested another ILS approach 

to runway 4. The flight was vectored for another ILS approach, and at 1110:07 the approach 

controller advised the pilots of traffic 2 nm miles away at 5,000 feet. The captain responded that 

they were in the clouds. At 1014:38, the controller directed the pilots to reduce speed to follow a 

Cessna 172 on approach to the airport, and the captain responded, ìok weíre slowing.î The flight 

was cleared for a second approach at 1120:45 and advised to maintain 4,000 feet until the 

airplane was established on the localizer. 

At 1123:49 the captain transmitted, ìfor uh one six echo juliet weíd like to declare an 

emergency.î At 1123:53, the approach controller asked the nature of the problem, and the captain 

responded, ìengine failure.î The approach controller acknowledged the information, informed 

the pilots that the airplane appeared to be south of the localizer (off course to the right), and 

asked if they wanted a vector back to the localizer course. The flight crew accepted, and at 

1124:10 the controller directed a left turn to heading 010, which the captain acknowledged. At 

 3

 ATC radar indicated that the airplane approached AVP from the southeast at an initial altitude of 5,000 feet. 

4

 No information was recorded on the cockpit voice recorder (CVR). ATC transcripts are the only record of pilot 

communication. See the CVR Maintenance section for information about the CVRís failure to record information. 5

 The ILS is a precision approach system that provides lateral alignment (localizer) and vertical guidance 

(glideslope) with the runway. 6

 The Crystal Lake non-directional beacon is located about 8.4 nm from the runway 4 threshold. 

7

 Decision altitude (DA) is a specified altitude at which a missed approach must be executed if visual references 

have not been established. DA for the ILS runway 4 approach is 1,263 feet msl, or about 300 feet above the runway 

touchdown zone. 8

 The airplane was about 2.5 nm from the runway threshold when it began to climb on the missed approach. 
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1124:33, the controller asked for verification that the airplane was turning left. The captain 

responded, ìweíre trying six echo juliet.î At 1124:38, the controller asked if a right turn would 

be better. The captain asked the controller to ìstand by.î At 1125:07, the controller advised the 

pilots that the minimum vectoring altitude (MVA) in the area was 3,300 feet. At 1125:12, the 

captain transmitted, ìstandby for six echo juliet tell them we lost both engines for six echo 

juliet.î At that time, ATC radar data indicated that the airplane was descending through 3,000 

feet. 

The controller immediately issued the weather conditions in the vicinity of the airport and 

informed the flight crew about the location of nearby highways. At 1126:17, the captain asked, 

ìhowís the altitude look for where weíre at.î The controller responded that he was not showing 

an altitude readout from the airplane9

 and issued the visibility (2.5 miles) and altimeter setting. At 

1126:43, the captain transmitted, ìjust give us a vector back to the airport please.î The controller 

cleared the accident flight to fly heading 340, advised the flight crew that radar contact was lost, 

and asked the pilots to verify their altitude. The captain responded that they were ìlevel at 

2,000.î At 1126:54, the controller again advised the flight crew of the 3,300-foot MVA and 

suggested a 330° heading to bring the airplane back to the localizer. At 1127:14 the controller 

asked, ìdo you have any engines,î and the captain responded that they appeared to have gotten 

back ìthe left engine now.î At 1127:23, the controller informed the pilots that he saw them on 

radar at 2,000 feet and that there was a ridgeline between them and the airport. The captain 

responded, ìthatís usî and ìweíre at 2,000 feet over the trees.î The controller instructed the 

pilots to fly a 360° heading and advised them of high antennas about 2 nm west of their position. 

At 1127:46, the captain transmitted, ìweíre losing both engines.î Two seconds later the 

controller advised that the Pennsylvania Turnpike was right below the airplane and instructed the 

flight crew to ìlet me know if you can get your engines back.î There was no further radio contact 

with the accident airplane. The ATC supervisor initiated emergency notification procedures. A 

Pennsylvania State Police helicopter located the wreckage about 1236, and emergency rescue 

units arrived at the accident site about 1306. The accident occurred in daylight instrument 

meteorological conditions (IMC). The location of the accident was 41° 9 minutes, 23 seconds 

north latitude, 75° 45 minutes, 53 seconds west longitude, about 11 miles south of the airport at 

an elevation of 1,755 feet msl. 

Witness Statements 

The Safety Board interviewed several witnesses who were along the accident airplaneís 

flightpath and near the accident site at the time of the accident. One witness located near the 

crash site stated, ìthe aircraft was making a very loud sound as if overspeeding and slowing 

down at different times. A short time later, the engines stopped.î The witness added, ìthe planeís 

engines sounded unusually loud to me as if they were being accelerated to the maximum. A few 

seconds later, the sound of the engines stopped. A few seconds after that, the sound of the 

 9

 The airplane had descended below the MVA of 3,300 feet and radar was unable to record its altitude because 

of terrain interference. 
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NTSB/AAB-02/05 

engines started a short distance away from the location I originally heard the airplane and soon 

thereafter, once again stopped.î 

A second witness in the vicinity of the crash site stated, ìI heard the engines cut out but 

the turbines continued to whineÖsoon after that, I heard the whining of the turbines but 

definitely the engine was not running.î Another witness, who was in the vicinity where the pilots 

radioed that they had lost an engine, stated that he heard an engine noise that was ìvery loud, 

irregular running, with a real rough grinding noiseÖthe sound pitched up and down in cycles.î 

PERSONNEL INFORMATION 

Both flight crewmembers were certificated under company and FAA certification 

requirements. A review of FAA records indicated that the flight crewmembers had no record of 

airplane accidents, incidents, or enforcement actions. In addition, the flight crewmembers held 

valid driverís licenses with no history of accidents or violations during the 3 years before the 

accident. A search of the National Driver Registry found no history of driverís license revocation 

or suspension for either flight crewmember. 

The Captain 

The captain, age 34, was hired by Executive Airlines in April 1998 as a part-time pilot. 

He was also a full-time pilot for Atlantic Coast Airlines (ACA), where he had started working in 

December 1992. At ACA, he was a captain on the Jetstream 3200 and the Jetstream 4100. He 

held an airline transport pilot (ATP) certificate, issued on May 17, 2000, and type ratings in the 

Jetstream 3100, Jetstream 4100, and Dornier D-328 jet. His most recent FAA first-class medical 

certificate was dated December 16, 1999, with no restrictions or limitations. At the time of the 

accident, the captain had accumulated about 8,500 flying hours, including about 1,874 hours as 

pilot-in-command in the Jetstream. According to the captainís wife, the captain had flown 

previously with the accident first officer and considered him to be a good pilot. 

According to his family, the captain awoke about 0600 on the day of the accident. His 

wife spoke to him just after he awoke, and she stated that he seemed very happy. On the day 

before the accident, the captain awoke about 0845 and went to his sonís little league game, which 

started at 0900. The captain took a nap on Saturday afternoon from 1300 to 1600. He went out to 

dinner that evening with his wife. He went to bed about 2200 because he had to get up for the 

early flight. His wife stated that when he was not working, the captain usually went to bed about 

2300 and awoke between 0800 and 0900. There was no family recall of what the captain did on 

Friday, 2 days before the accident. 

The First Officer 

The first officer, age 38, was hired by Executive Airlines on November 9, 1998. He held a 

commercial pilot certificate issued on May 19, 1998. His most recent FAA first-class medical 

certificate was dated January 28, 2000, with no restrictions or limitations. According to 
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NTSB/AAB-02/05 

Executive Airlines records, he had accumulated about 1,282 total flying hours, of which about 

742 hours were in the Jetstream 3101. 

According to the first officerís fiancÈe, the first officer had received a job offer on the 

Friday before the accident to fly with a regional airline. She stated that the first officer was 

excited about the new position and that the captain had helped the first officer prepare for job 

interviews during down times in ACY. 

 The first officerís fiancÈe reported that on the day of the accident, the first officer arose at 

0600. He showered and ate breakfast. En route to the airport, he stopped for coffee, a bagel, and 

orange juice. He met the captain at the airport around 0815. 

The day before the accident, the first officer departed ACY about 0130 on a routine flight 

to FRG that arrived at 0200. His fiancÈe was on the flight. They had a 20-minute drive home and 

went to sleep. He slept late and spent the day around the house. They watched TV and went out 

for lunch about 1400 to 1500. He went to bed on Saturday night about 2200 to 2230. 

Two days before the accident, the first officer went on duty about 1400 and flew a series 

of flights for a total flight time of 6 hours and 42 minutes. His fiancÈe saw him in ACY about 

1930 when they got together and had dinner at the airport. She stated that his mood was good and 

that after dinner he went to the pilot lounge for a nap. 

AIRPLANE INFORMATION 

According to FAA and company records, the accident airplane, serial number 834, was 

manufactured in 1988 by British Aerospace. The cabin was configured for 19 passenger seats, 

with 7 single passenger seats on the left side of the airplane, and 6 double passenger seats (12 

total) on the right side of the airplane. At the time of the accident, the airplane had accumulated 

about 13,972 flight hours and about 18,503 cycles since new (CSN).10 FAA records indicated that 

the airplane was imported to the United States from the United Kingdom in 1988 and that it was 

assigned aircraft registration number N851JS. Executive Airlines purchased the airplane on 

October 28, 1996, from Fairchild Dornier of Sterling, Virginia. The accident airplaneís 

registration was changed to N16EJ in September 1997. The airplane entered Executiveís line 

service on December 19, 1997. 

A review of FAA and Safety Board accident and incident files indicated that the accident 

airplane was substantially damaged when it veered off a runway and impacted terrain during an 

aborted takeoff in snow conditions on December 15, 1989. In addition, on February 19, 1991, 

during cruise flight, an engine fire warning bell sounded. The crew shut down the engine and 

landed safely. There were no other accident or incident reports. 

 10 A cycle is one complete takeoff and landing sequence. 
6 

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Airplane Engines and Propellers 

The accident airplane was equipped with two Honeywell (formerly AlliedSignal) model 

TPE331-10UGR-514H turboprop engines. This model engine is a single-spool design consisting 

of a dual centrifugal compressor, reverse-flow annular combustor, and a 3-stage axial flow 

turbine. It is rated at 940 shaft horsepower for takeoff and has a maximum continuous rating of 

900 shaft horsepower. 

At the time of the accident, the No. 1 (left) engine, serial number P63344C, had 

accumulated 14,027.5 hours time since new (TSN), 18,602 CSN, and 469 hours since the last 

overhaul. The last engine inspection performed was a 150/300-hour inspection on March 15, 

2000. The engine had 13,853.4 hours TSN and 18,361 CSN at the time of the last inspection. 

 

The No. 2 (right) engine, serial number P63328C, had accumulated 5,939.5 hours TSN, 

6,017 CSN, and 56.9 hours since last overhaul. The last engine overhaul before the accident was 

performed on April 25, 2000, and the last operational check, ground runs, and leak checks were 

performed on May 10, 2000, when the engine was installed on the accident airplane. 

The accident airplane was equipped with two Dowty model R333/4-82-F/12 singleacting, full-feathering,11 constant speed, 4-blade propellers, which rotate counter-clockwise as 

seen from the cockpit. The No. 1 propeller, serial number DRG/598/82, had accumulated 

14,047.8 hours TSN and 945.0 hours since overhaul. The No. 2 propeller, serial number 

DRG/1747/88, had accumulated 14,446.8 hours TSN and 3,822.1 hours since overhaul. 

The propeller governor supplies oil pressure to drive the propeller to a low-pitch position 

(small blade angle) while the feathering spring drives the propeller to high blade angles, 

including feather. To maintain a constant speed, the propeller governor uses mechanical 

flyweights to position a metering valve that supplies oil pressure to the propeller dome. Propeller 

speed is maintained by modulating the blade angles to increase or decrease the load on the 

propeller. 

The propeller governor cannot drive the blades lower than the low-pitch stop. Governor 

oil flows through a set of holes in the beta tube and out to the propeller dome. As the blade angle 

changes, the position of the beta tube changes. The beta tube slides inside a bronze bushing that 

covers the oil supply holes in the beta tube as the blade angle approaches the low-pitch stop (so 

that less oil flows to the propeller dome). The supply holes are completely covered when the 

blades are at the low-pitch stop, preventing additional oil from flowing to the propeller dome and 

 11 When an engine fails in flight, the windmilling propeller creates drag and causes the airplane to yaw. 

Feathering a propeller rotates the leading edges of the propeller blades into the slipstream, which minimizes or stops 

the rotation of the propeller blades and, thus, reduces drag caused by the propeller. 
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NTSB/AAB-02/05 

a further blade angle decrease into the beta range.12 To move the propeller into the beta range, the 

engine power lever must be reduced, which mechanically repositions the bronze bushing on the 

beta tube and allows governor oil pressure to flow to the propeller dome again, further reducing 

the blade angle and driving the propeller into the beta range. 

Airplane Fuel System 

The Jetstream 3101 is equipped with one fuel tank in each wing (see figure 1), and each 

has a maximum usable capacity of 227 U.S. gallons.13 Each tank is divided into five cells (cell 

No. 1 is the most inboard and cell No. 5 is the most outboard) with flapper valves installed 

between the cells to limit fuel sloshing. Six fuel probes are installed in each tank and are 

connected to the cockpit fuel quantity gauges. A booster pump is installed in each tank to supply 

each respective engine. Downstream of each booster pump is a line-mounted, one-way check 

valve to prevent fuel transfer between tanks during crossfeed operations. A two-position, 

electrically operated crossfeed valve connects the left and right engine fuel feed lines when open. 

Low pressure (LP) fuel valves are installed in each system to isolate the fuel system in the event 

of an engine fire. The respective LP fuel valve closes if the associated feather lever is selected. 

Each wing tank contains an independent low fuel level system that illuminates small low 

fuel quantity annunciator light(s) in the cockpit if fuel levels fall below about 200 pounds in the 

respective tank. The low fuel quantity annunciator lights are located on the left center panel 

between the fuel quantity gauges. According to the Jetstream 31 Operating Manual, the low fuel 

quantity annunciator lights were not designed to be warning lights. The manual states that they 

are a means to confirm low fuel quantity. The airplane is also equipped with two independent 

fuel quantity gauges and two fuel flow/fuel used indicators, one for each engine. An analog point 

continuously displays each engineís fuel flow rate. The indicator also has a 4-digit numerical 

display that shows fuel used for each engine. A small toggle switch allows the flight crew to reset 

(to zero) the fuel used display. The fuel used display automatically resets to zero when airplane 

power is shut off. 

 12 According to the BAE Jetstream 31 Crew Manual, in the beta mode, or the propeller reverse mode, propeller 

blade angles are ìdirectly related to the engine power lever setting between reverse and flight idle positions.î The 

manual further states that the propeller ìhas a pitch range between reverse and feather.î The propeller also operates 

in the propeller governing mode, when ìblade angles are controlled to maintain the rpm set by the engine rpm 

leverÖwhen the power lever is advanced above flight idle position.î The beta, or reverse, mode is used to decelerate 

the airplane after landing. 13 According to the Jetstream 31 manual, about 5 U.S. gallons (about 33 pounds) are unusable in each tank. The 

amount of unusable fuel varies depending on airplane configuration. During certification, the manufacturer tested the 

Jetstream 31 for usable fuel in five phases of flight. The unusable fuel quantity ranged from 7 pounds 15 ounces to 

33 pounds depending on the phase of flight/airplane configuration. For example, the largest unusable fuel quantity, 

33 pounds, was measured in a climb at 110 knots, flaps at 10°, in a 5° bank with the booster pump off. The minimum 

quantity, 7 pounds 15 ounces was measured in level flight at 230 knots, in a 5° bank with the booster pump off. 

Jetstream publishes the most conservative configuration, 33 pounds of unusable fuel in each tank in the Jetstream 31 

flight manual. In addition, fuel volume in the fuel lines (between the respective tank and the engine) is about 

1.5 gallons. 
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Figure 1. Diagram of the Jetstream Series 3100 fuel system (from the Jetstream Series 3100 

Training Guide) 

Cockpit Voice Recorder 

The Fairchild cockpit voice recorder (CVR) was recovered from the accident scene and 

transported to the Safety Boardís laboratory in Washington, DC, for examination. The CVR was 

damaged by impact forces but showed no evidence of fire damage. The impact damage was 

primarily confined to the connector plug, dust cover, and adjacent chassis. The magnetic tape 

was removed from the CVR and examined. The entire recording was monitored. No information 

pertaining to the accident flight or any other flight was found. A 400 hertz (Hz), 20 decibel tone, 

approximately 1.8 seconds in duration, was present on all four channels at the end of the 

recording. The remainder of the tape contained a signal consistent with a trace signal of bulk 

erase activation. (See the Maintenance section and the Tests and Research section later in this 

report for details about the accident airplane CVR and its maintenance history). The CVR impact 

inertia switch14 was found in the ìopenî position when initially tested in the Safety Boardís 

laboratory. Subsequent testing indicated that the switch was serviceable (that is, the switch would 

open when subjected to impact shock and could be reset to the closed position using the manual 

reset button). 

No flight data recorder (FDR) was installed on the accident airplane, nor was one 

required. 

 14 The impact switch interrupts the CVR power supply when subjected to a 4-G impact force. The switch can 

only be reset by manually depressing the reset button on the side of the switch. 
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Weight and Balance 

Weight and balance calculations were performed using the accident airplaneís records, 

the Executive Airlines operatorís manual, and the manufacturerís flight manual. Calculations 

(which included 2,890 pounds assumed for 17 passengers) showed that the airplane could have 

contained as much as 2,192 pounds of fuel and remained within ramp and takeoff weight 

limitations when departing ACY. 

METEOROLOGICAL INFORMATION 

No significant surface weather features or upper air disturbances were present over the 

northeastern United States on the day of the accident. Radar and other data indicated widespread 

cloudiness and scattered light rain showers over the region. 

The AVP surface weather observation current at the time that N16EJ executed its missed 

approach reported cloud layers at approximately 1,700 feet msl broken and 2,500 feet msl 

overcast.15 In addition, a tower controller reported lower clouds on the approach end of the 

runway, and a previous landing airplane reported near minimum conditions on the approach. 

Upper air, satellite, radar, and numerical model data indicated that the winds at and below 

3,000 feet msl in the vicinity of AVP were likely from 220° to 250° at 5 to 10 knots. The 

temperature at 3,000 feet was about 7.5° Celsius (C) increasing to 11° C at the surface. The 

freezing level in the AVP area was about 9,300 feet msl. 

The following official weather observation was current near the time of the accident 

airplaneís second approach to AVP: 

Timeó1123; typeóSPECI; windó260 degrees at 3 knots; visibilityó2 1/2 miles; 

present weatherómist; sky conditionóbroken 500 feet agl broken 900 feet agl [above 

ground level] overcast 1,500 feet agl; temperatureó11 degrees C; dew pointó

11 degrees C; altimeter settingó30.04 inches hg; remarksórain began 1108 ended 1117 

Regional weather observations and satellite imagery indicated overcast cloud layers over 

New Jersey and eastern Pennsylvania with cloud ceilings below 1,500 msl. Cloud tops of the 

lower layers varied between 5,000 feet and 9,000 feet msl. The en route winds between 

4,000 feet and 5,000 feet msl were from 230° to 250° at 10 to 15 knots. The en route freezing 

level was about 10,000 feet msl. 

AIRPORT INFORMATION 

AVP, is at an elevation of 962 feet msl and is located about 5 miles southwest of WilkesBarre/Scranton. The active runway at the time of the accident was runway 4. Runway 4 is 

7,501 feet long and equipped with an ILS, including high intensity runway lights, a medium 

 15 According to FAA data, N16EJ descended to 2,200 feet msl before declaring a missed approach at 1107:42. 
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NTSB/AAB-02/05 

intensity approach lighting system with runway alignment indicator lights, and a 3° precision 

approach path indicator located on the right side of the runway. 

WRECKAGE INFORMATION AND IMPACT INFORMATION 

The airplane wreckage was found on the top of a mountain on the east side of a pipeline 

clearway on state-owned property. Ground and tree impact marks indicated that the airplane 

impacted terrain at a steep angle and in an extreme bank angle. Witness marks on the attitude 

indicator, ground witness marks, airplane crushing, and other damage indicated that the airplane 

impacted the ground at a 60° nose low attitude and in a 135° left bank. Ground scars indicated 

that the airplane impacted the ground on a 40° heading. All of the airplaneís primary structure 

was located at the accident site. All recovered primary and secondary flight control surfaces were 

found at the accident site. As shown in figure 2, fire damage was confined to the immediate 

impact area, with little fire damage to surrounding trees and foliage. 

Figure 2. Photo of the accident site illustrating the lack of fire damage to the surrounding area. 

The fuselage structure was found upright, in two major pieces, oriented on a 220° 

heading, with the right outboard wing folded up at a 90° angle. There was no evidence of inflight fire, such as metal splattering, soot streaking, or heat damage along any horizontal plane. 

All heat damage and postcrash fire signatures were in the vertical direction. 

The cockpit area was destroyed by impact and mostly consumed by the postcrash fire. 

The flight instruments, engine instruments and flight controls sustained severe fire damage. The 

cockpit roof switch panel was consumed by fire. The cockpit area had impact crushing damage 
11 

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from the rudder pedals through the instrument panel. All parts of the flight control system that 

were recovered were heat damaged and fragmented. Only small fragments of the aileron control 

handwheels were found, and the aileron longitudinal control shafts were found in multiple 

sections. All four rudder pedals were found separated. The elevator torque shaft was found in 

multiple segments. The aileron, rudder, and elevator trim cable drums were separated from their 

support structure and were severely heat damaged. The trim cables were not broken. 

The flap selector was not found; the flap position indicator sustained severe heat damage 

and the position needle and stencil were consumed by the postcrash fire. All the switches and 

indicators aft of the power levers on the center pedestal were consumed by the postcrash fire. The 

empennage was found rotated 180° about its longitudinal axis. It was separated from the aft 

fuselage structure and inverted but remained attached to the remnants of the forward fuselage by 

cables and wire bundles. The empennage had minimal heat and soot damage. The lower outside 

empennage surface had light vertical sooting and some heat discoloration but no paint blistering. 

The rudder was attached to the vertical stabilizer by its attach points. Teardown of the 

rudder trim mechanical screw jack revealed that it was extended approximately to the full 

airplane-nose-right position.16 The rudder trim control cables remained attached to the 

empennage and rudder system but were stretched and twisted from the airplaneís impact 

sequence. Because of this impact damage, the pre-impact rudder trim position could not be 

determined. 

The left elevator was attached to the left horizontal stabilizer by its attach points. A tree 

trunk was lying on top (chordwise) of the elevator and horizontal lower surfaces with 

corresponding crushing damage to the lower skin. The right horizontal stabilizer with elevator 

attached was found about 32 feet north of the empennage structure. The right horizontal stabilizer 

had been torn from its spar attach points near the vertical stabilizer. A large indentation 

(crushing) was located on the leading edge of the stabilizer; the diameter of which matched a 

nearby tree. None of the elevator or rudder control cables that remained in the empennage 

exhibited any damage. The cable runs forward of the empennage were severely heat damaged due 

to the postcrash fire; however, all the cables were unbroken up to the cockpit area. 

The left wing was found with extensive leading edge crushing. It had extensive heat 

damage and a portion of the upper skin was consumed by fire. The left inboard wing section 

between the engine nacelle and the fuselage was destroyed by fire. The left aileron had severe 

heat damage and was fractured just outboard of the inboard hinge. The inboard hinge was intact, 

but the outboard hinge point was separated. The inboard portion of the trim tab was intact and 

moved freely. 

 16 The airplaneís rudder is controlled by a torsion bar mechanism and a combined trim/spring tab. Control inputs 

from the rudder pedals are transmitted by quadrants, cables, and pulleys to the rudder torsion bar, which twists 

against aerodynamic loads and drives the trim/spring tab to provide servo assistance. Rudder trim is controlled by 

rotating a trim control knob in the cockpit. The trim control knob is connected to the cable control system, which 

extends or retracts the trim screw jack output shaft. The screw jack, mounted on the top of the torsion bar, drives the 

torsion bar mechanism to deflect the trim/spring tab to relieve rudder forces. 
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NTSB/AAB-02/05 

The right wing was mostly separated from the fuselage but attached by cables and parts of 

the wing spars. The inboard wing structure was consumed by fire. The outboard wing section 

exhibited decreasing fire damage toward the wing tip. The bottom part of the bent wing structure 

had numerous tree impact marks and bark imbedded in the structure. The wing fuel tank was 

ruptured in several places consistent with impact damage. The right aileron was broken from its 

hinge points but was still in its approximate position on the wing. The trim tab was intact but 

could not be moved because of impact damage. The aileron system cables were unbroken but 

severely heat damaged in areas associated with the postcrash fire. 

The majority of the left and right flap panels were broken and consumed in the postcrash 

fire. The flap actuator was found with the flap torque shaft attached. The flap actuator was found 

in its approximate position in the center fuselage area and was severely heat damaged. 

Examination of the flap actuator at the manufacturer determined that the position of the piston 

was consistent with a 20° flap setting. 

The left and right main landing gear actuating cylinders were found in the extended 

position but were separated from their attach points and burned. The nose gear strut and wheels 

were found folded back along the fuselage and were not damaged by fire. The nose gear actuator 

was found separated from the nose gear strut cylinder and in the extended position. The cylinder 

and extension assembly were found in the extended position but were separated from the 

fuselage attach points. 

The stick pusher17 actuator was recovered in good condition with no heat damage. 

Examination determined that the actuator was operational. 

Fuel System Wreckage 

The left engine low pressure (LP) fuel valve actuator was found separated from its valve 

and the right engine LP fuel valve was found intact. The valve position indicators on both valves 

were in the open position, consistent with the observed valve positions. The left and right 

hydraulic LP cocks were also found in the open position. The crossfeed valve was found in a 

clump of melted aluminum. The melted aluminum was removed and the crossfeed valve position 

indicator was found in the closed position, consistent with the observed valve position. The LP 

fuel cock switches in the cockpit were consumed by the postimpact fire. 

As previously noted, the low fuel quantity annunciator lights in the cockpit are located on 

the left center panel between the fuel quantity gauges. The main portion of the left center panel 

was found separated but approximately in its original location and with severe heat and impact 

damage. The lower third of the panel had been consumed and the fuel flow gauges and fuel 

quantity gauges had separated from the panel and were not identified. The low fuel quantity 

annunciator lights were consumed by the postcrash fire. 

 17 The stick pusher is part of a stall prevention system. When triggered, the stick (control column) is forced 

forward, commanding the airplane to rotate from a climb to a shallow dive. About 80 pounds of force is required on 

the control wheel to override. 
13 

NTSB/AAB-02/05 

The right tank fuel booster pump was found separated in its approximate original position 

in the wreckage (most of the right inboard wing structure was consumed in the postcrash fire). 

The pump showed signs of surface deformation from extreme heat damage. The left booster 

pump was heavily sooted and was attached to the rib in fuel cell 1. 

The fuel booster pumps were removed from the wreckage and examined at the 

manufacturer. Because of extensive fire damage, the pumps could not be bench tested. Both 

pumps were disassembled and examined. No rotational scoring was found on either armature.18

The left fuel filler cap was attached to its respective fuel port. The capís inside face was 

deformed by heat damage and was covered with melted and resolidified aluminum. The right fuel 

filler cap was not attached to its respective fuel port and the cap was not found. The filler cap 

ports were removed from the airplane and sent to the Safety Boardís materials laboratory for 

examination. 

The right fuel port had a chordwise wrinkle mark that intersected the port and was 

consistent with the localized upward bending of the upper skin. Examination of the interior face 

of the portís lip revealed circumferential marks, consistent with normal rotation of the filler cap. 

In addition, the lip contained three areas of localized outward deformation.19 A chordwise gouge 

mark was found on the interior surface of the lip in one of those areas. Metallurgical examination 

determined that the localized deformation and gouge mark were consistent with the right fuel 

filler cap being attached before impact. 

The main fuel lines from each engine were recovered from the wreckage and sent to the 

Safety Boardís materials laboratory for examination. A visual inspection determined that the lines 

were intact. No evidence consistent with kinking or blockage was found. 

On-site Examination of Engines and Propellers 

Both engines and their respective propellers were found at the crash site. After an initial 

on-site inspection, they were removed to a hangar at AVP for a detailed, preliminary inspection 

before being transported for extensive teardown inspections (see the Tests and Research section 

for details of the teardown inspections). 

The No. 1 (left) engine was found partially attached to the left wing. There was no visible 

sign of any uncontained engine failure (that is, engine parts exiting the casing) or fire damage in 

the engine. The No. 1 engine was bent inboard toward the airplaneís centerline, at a 35° angle, 

just forward of the wing spar, and was lying over on its right side. The rear engine mount was 

found intact, and the forward mounts, located at the 3, 6, and 9 oíclock positions, were broken 

 18 The booster pumps do not operate continuously and are normally used for engine start, high altitude operations, 

fuel balancing, or abnormal or emergency situations. 19 Each filler cap contains three tangs, or legs, spaced equally around the circumference, which are inserted into 

slots in the lip of the fuel port. The cap is then rotated clockwise to secure the cap. 
14 

NTSB/AAB-02/05 

out of the accessory gearbox. The 3rd-stage turbine blades, as viewed up the tailpipe, all 

appeared intact with no obvious signs of distress. The propeller remained attached to the engine. 

Minimal external fire damage was found on the No. 1 engine, and all of its systems and 

accessories were generally intact with the exception of a broken starter/generator input shaft. Dirt 

and debris were found around the inlet circumference and on the 1st-stage compressor blades. 

The 1st-stage compressor blades were all intact with no signs of distress, and the rotating group 

was seized. The auto-ignition system was installed and intact. The aircraft electrical connector 

was still connected to the auto-relight pressure switch. The three negative torque system (NTS)20

load arms were intact. The gearcase was cracked in two places from front to back. 

Blade No. 1 of the No. 1 engineís propeller was found fractured 9 inches outboard from 

the hub flange. The tip of blade No. 1 was curled, and the blade had an ìSî shape, bent in the 

direction opposite rotation. A 5-inch long impact/depression was centered 17.5 inches from the 

fracture surface that was closest to the hub. The counterweight was missing. Blade No. 2 had 

minor impact marks on the leading edge and the anti-ice boot was ripped. The No. 3 blade had a 

1.5-inch depression on the leading edge that was centered 34 inches outboard from the hub. 

Blade No. 4 had a 5-inch leading edge dent/impact mark that was centered 40.5 inches outboard 

from the hub and was missing 2 inches of the blade tip. Blade No. 4 also had smaller impact 

marks along the leading edge, and its anti-ice boot was torn along the leading edge. The pressure 

side of blade No. 4 had scrape marks approximately 45° to the length of the blade. Blade No. 4 

was the only blade that was able to rotate within the hub. Blades 2 and 4 were bent in the 

direction of rotation. Blade No. 3 was slightly bent opposite the direction of rotation. The hub 

was fractured at the No. 2 blade position; the crack extended axially and circumferentially 

through the hub from one of the No. 2 blade attachment bolt holes. The No. 1 engineís propeller 

governor21 was recovered undamaged and contained residual oil. A bench test determined the 

propeller governor functioned within limits. 

The No. 2 (right) engine was found partially attached to the right wing. The propeller 

assembly was attached to the engine. The engine was bent about 30° nose-down and 20° inboard. 

The outside of the engine was heavily fire damaged and the inlet case exhibited a burn-through. 

There were no visible signs of any uncontainments. The rear engine mount was intact and the 

forward engine mount, located at the 9 oíclock position, was fractured. 

 

All the 1st-stage compressor blades were intact with no obvious signs of distress. The 

3rd-stage turbine blades were all intact with no obvious signs of distress, and the rotating group 

was seized. The anti-ice system and its plumbing were intact. The propeller pitch control flange 

was partially separated from the gearbox. The inner contour of the inlet scoop was fractured 

 20 Negative torque is a condition in which air loads on the propeller drive the engine. The NTS system is 

designed to sense this condition and modulate the propeller blade angles to prevent it from occurring. 21 The propeller governor is a device that is used to control the speed of the propeller by using either governor 

oil pressure to drive the blades to a fine pitch or the force of the feathering spring to drive the blades to a course 

pitch. This blade angle change controls the propeller speed by either decreasing or increasing the load on the 

propeller. In the event of a loss of governor oil pressure, the feathering spring would drive the blades to the feathered 

position (failsafe mode) to minimize the drag on that side of the airplane. If necessary, the Jetstream 31ís propellers 

can be unfeathered in flight. 
15 

NTSB/AAB-02/05 

circumferentially from about the 10 oíclock to the 2 oíclock position. The fuel control was 

severely fire damaged. 

The No. 2 engineís propeller assembly had three blades intact and one blade fractured. 

Blade No. 2 was fractured 34 inches outboard from the hub. Blade No. 3 was bent in the 

direction of rotation. Blade No. 3 had a sharp bend, slightly less than 90°, located 17 inches 

outboard from the hub. Blades No. 1 and No. 4 were straight. Blade No. 2 was the only blade that 

could be rotated within the hub. With the exception of blade No. 2, none of the other three blades 

had any significant leading edge damage. All of the blade counterweights were in place. 

The No. 2 engineís propeller governor drive spline was seized, consistent with the 

combined effects of impact forces, fire damage, and rust. The governor was disassembled and all 

components were found intact and without evidence of any internal failures. 

SURVIVAL ASPECTS 

The accident was not survivable because of high impact forces. Autopsies determined that 

the passengers and flight crew died of blunt force trauma. 

MEDICAL AND PATHOLOGICAL INFORMATION 

Tissue specimens from the captain and first officer were recovered and transported to the 

FAAís Civil Aerospace Medical Institute (CAMI) for toxicology analysis. The CAMI laboratory 

performed a routine analysis for major drugs of abuse22 and prescription and over-the-counter 

medications, and the results were negative. The FAAís Final Forensic Toxicology Fatal Accident 

Report indicated that 15 milligrams per deciliter of ethanol was detected in a kidney sample from 

the first officer (a muscle sample tested negative). The report noted that the ìethanol found in this 

case may potentially be from postmortem ethanol formation and not from the ingestion of 

ethanol.î 

TESTS AND OTHER RESEARCH 

Airplane Performance 

The accident airplaneís performance during the final 30 minutes of flight was calculated 

based on FAA three-dimensional radar data,23 ATC communications, weather information, and 

aircraft aerodynamic performance data obtained from the manufacturer. The data were used to 

calculate performance parameters including airspeed, groundspeed, altitude, vertical speed, 

flightpath angle, pitch and roll angles, and magnetic heading. Upper wind data (wind direction, 

speed, and air temperature) were obtained from the FDR of a regional jet that had departed AVP 

about an hour before the accident. 

 22 The five drugs of abuse tested in postaccident analysis are marijuana, cocaine, opiates, phencyclidine, and 

amphetamines. 23 ATC airport surveillance radar at AVP and air route surveillance radar data were obtained from the FAAís 

New York Air Route Traffic Control Center. 
16 

NTSB/AAB-02/05 

Examination of the wreckage indicated that the airplaneís flaps had been extended to 20° 

and that the landing gear was extended at impact. Aerodynamic information was obtained from 

British Aerospace for the airplane in several configurations, including flaps retracted, flaps 

extended to 20°, and with landing gear in the stowed and deployed position for the flap settings. 

The performance study determined that during the first approach, the accident airplane 

descended to about 4,000 feet and turned to a 45° heading (the localizer heading) about 12.5 nm 

from the end of runway 4 (figure 3 shows the approach chart for the ILS runway 4 approach). 

The airplane intercepted the localizer at 4,000 feet (about 1104:50) and was descending between 

900 feet and 1,000 feet per minute (fpm). The aircraft began to follow the glideslope about 9 nm 

from the runway. The airplane followed the center of the localizer and glideslope until it leveled 

off at 2,200 feet about 1106:50, about 3.7 nm from the runway threshold. The airplane was level 

at 2,200 feet for about 20 seconds and then began to climb while still following the center of the 

localizer. The airplane exited the localizer while at 2,900 feet, about 2.2 nm from the end of the 

runway. 

After the missed approach was declared, the airplane began to climb at a rate of 

2,000 fpm, reaching an altitude of 4,000 feet and an airspeed of 200 knots by 1108:30 (the climb 

was consistent with the airplaneís expected twin-engine performance in such conditions). The 

airplane continued on the missed approach at 4,000 feet and 180 knots. After establishing a track 

to intercept the localizer, the airplane began reducing speed while continuing a right turn on the 

intercept course. At 1123:10 the airplane began descending at 300 fpm, and its airspeed 

continued to decrease (reaching about 128 knots during the following minute). The airplane was 

again on the localizer course when, at 1123:20, the accident airplane began to deviate to the right 

of the localizer track. 

The accident airplane was at an altitude of 3,800 feet when the flight crew declared an 

emergency at 1123:51 (see figure 4). By this time, the airplane had deviated from the specified 

45° approach course to about a 70° heading, had slowed to about 125 knots airspeed, and was 

about 12 nm from the runway threshold. The airplane continued to turn right. At 1124:14, when 

ATC instructed the flight crew to turn left, and a crewmember responded ìweíre trying,î the 

airplane was on a 100° heading, or about 55° off of the desired heading and to the right of the 

specified approach course. About a minute later, when the crew radioed that it had lost both 

engines, the airplane was in a steeper descent, descending about 1,500 fpm at 130 knots airspeed. 

The airplane then turned to the left to a 90° heading and radar contact was temporarily lost. 

Airspeed increased to 140 knots as the airplane descended through 2,100 feet. 
17 

NTSB/AAB-02/05 

Figure 3. Approach chart for the ILS runway 4 approach at AVP. 
18 

NTSB/AAB-02/05 

Figure 4. Plot of the accident airplaneís initial and second approaches correlated with key ATC 

transmissions. 

At 1127:16, when the pilots radioed that they had apparently regained power to the left 

engine, the airplaneís heading would have been about 285°. The next radar return occurred at 

1127:23. According to the performance calculations, the accident airplane would have had to 

execute a right turn while maintaining about 2,000 feet in a northwesterly direction to reach that 

radar return location. The final series of radar returns showed the airplane at 2,000 feet and an 

airspeed of 103 knots. The data indicated that the airplane continued to turn right at the same 

altitude and airspeed. The final radar return occurred at 1127:48, 2 seconds after the captain 

reported losing both engines. The crash site was about 0.22 nm north of the final radar return. 
19 

NTSB/AAB-02/05 

Fueling History and Fuel Burn 

Safety Board investigators examined fueling records and interviewed company officials, 

fuelers that serviced the accident airplane, and passengers on the flight from FRG to ACY to 

determine the accident airplaneís recent fueling history. Executive Airlines billing records, load 

manifests from some flights, and company records of the accident airplaneís recent flights were 

also examined. The load manifest for the flight from ACY to AVP was not recovered from the 

wreckage. 

Executive Airlinesí owner and CEO stated that about 0100 on the day of the accident, he 

received a telephone call from a captain who had been originally assigned to ferry the accident 

airplane from FRG to ACY to pick up 17 passengers for AVP. That captain informed him that 

weather at ACY and AVP was marginal, that the airplane had only 1,200 pounds24 of fuel on 

board, and that the fixed base operator (FBO) fueling operation at FRG was closed. The CEO 

stated that he decided to cancel the flight and told the captain to hangar the airplane. He stated 

that he then contacted Caesarís Palace and rescheduled the flight for 1030. As previously 

discussed, the pilots of the accident airplane were instructed when they arrived at FRG to add this 

leg to the dayís flying schedule. 

The CEO stated that he originally told the accident first officer to calculate the airplaneís 

weight and balance based on nine passengers from ACY to AVP to determine if the airplaneís 

fuel tanks could be topped off with fuel in FRG. He stated that the first officer told him that fuel 

tank measuring sticks25 indicated that about 1,100 pounds of fuel were on board. The CEO stated 

that he learned that 17 passengers would be on board the flight from ACY to AVP and informed 

the first officer. He stated that the first officer informed him that 90 gallons (about 600 pounds) 

of fuel would be added to each tank and told him ìwe are going almost topped off.î The CEO 

added that according to company procedure, pilots ìwould normally stick the tanks and then 

order the fuel.î 

The FBO fueler at FRG stated that the accident flight crew was at the airplane when he 

arrived in his fuel truck.26 He stated that one pilot, whom he described as smaller than the other,27

requested that the fuel tanks be topped off. The fueler stated that the larger pilot later requested 

60 gallons of fuel, 30 gallons in each tank. He stated that he could not see the refueling meter 

while he was refueling and asked the larger pilot to monitor the meter. The fueler stated that, at 

one point, he stopped fueling and asked the pilot to tell him the meter indication and stated that 

he was told 4.5 (or 45 gallons). He stated that he asked the pilot if he wanted him to put 15 

gallons in the other tank for a total of 60 gallons. The fueler stated that the larger pilot told him to 

put 45 gallons in the other tank for a total of 90 gallons. Fuel truck and billing records confirmed 

 24 Fuel quantity is also expressed in pounds. According to the Jetstream 31 weight and balance manual, one 

U.S. gallon is about 6.66 (the Safety Board used 6.7) pounds, based on the density of the kerosene-type fuel used. 25 The fuel tank sticks are read by pulling them downward from built-in slot positions under the wings. 

26 The fueler stated that he had worked for the FBO for about 3 months and had refueled about 12 Jetstream 

airplanes before fueling the accident airplane. 27 Company records indicated that the accident captain was 74 inches tall and weighed 210 pounds. The first 

officer was 71 inches tall and weighed 165 pounds. 
20 

NTSB/AAB-02/05 

the purchase of 90 gallons of fuel. The pilots did not receive a copy of the fuel receipt because 

Executive Airlines had a fueling contract with the FBO. The fueler stated that he ìdid not 

observe either pilot check the fuel drip sticks, climb up the fuelerís ladder to check the fuel, or 

walk around the airplane.î 

The accident first officerís fiancÈe, who was a passenger on the first leg of the accident 

flight from FRG to ACY, stated that the first officer told her that one fuel gauge read 300 pounds 

and that the other read 900 pounds and that she subsequently saw these gauge readings herself. 

She stated that the 300-pound indication was ìthe right side.î She stated that the first officer 

remarked, ìI donít even know how to tell how much fuel we have on board.î She stated that the 

pilots did not remain outside the airplane during fueling because it was raining. She stated that 

she did not know if either pilot had been involved with the fueling. She stated that she was aware 

of the decision, made during discussion with the operatorís president, to top off the fuel tanks to 

avoid refueling in ACY. In a written statement, dated June 6, 2000, she stated that the captain 

ìwalked behind the aircraft to the right side to stick the tankî after learning of the added flight to 

AVP. She also stated, ìthe three of us remained in the aircraft during the fueling procedureÖand 

the door of the airplane was closed.î She also stated that she called the FBO in ACY28 to confirm 

that the manifest listed 17 passengers flying to AVP. The line serviceman at ACY, who 

marshaled the airplane for departure on the accident flight, stated that he recalled looking at the 

plane and ìdid not see any fuel coming out of or off the wing at any time.î 

Fuel burn estimates for the accident airplaneís flight legs between May 19, 2000, and 

May 21, 2000 were calculated. The estimates were based on approximate airplane weights from 

available weight manifests from the flights and fueling records. Altitudes used were based on 

information obtained from interviews with other Executive Airlines flight crews familiar with the 

flight legs. The taxi fuel burn was estimated at 6 pounds per minute, according to the Jetstream 

flight crew manual. 

According to the airplane manufacturer, the maximum fuel load was 3,090 pounds. When 

fueling records indicated a fill-up of the fuel tanks, 3,090 pounds was used in the Safety Boardís 

fuel calculations, which are presented in the following tables. During postaccident interviews, 

Executive flight crews indicated that it was a common practice to only put 2,900 pounds on the 

load manifest because flight crews assumed that the tanks were almost never filled to the top. 

The Director of Operations of Executive Airlines, who was also an instructor and a check 

captain on the Jetstream 31, stated that Executive pilots normally used high-speed climb power 

for the climb to altitude and used high-speed cruise power during the cruise portion of the flight. 

However, Executive Airlinesí owner and CEO stated that his pilots used long-range cruise power 

during cruise flight. Based on this information, the Safety Board calculated fuel burn for the nine 

previous flights and the accident flight using manufacturer performance information for 

high-speed cruise and long-range cruise power (presented in tables 1 and 2, respectively). Fuel 

burn calculations were based on flight times listed in the airplane logbook. 

 28 The first officerís fiancÈe was employed at the FBO in ACY. 
21 

NTSB/AAB-02/05 

According to these calculations, if high-speed cruise power settings were used on the nine 

previous flights and accident flight, about 275 pounds of fuel would have remained at the time of 

the crash (of which 209 pounds would have been useable using a 66-pound estimate of unusable 

fuel), which is sufficient fuel for about 15 minutes of flight at high-speed cruise power settings. If 

long-range cruise power settings were used, the airplane would have had about 1,220 pounds 

remaining at the time of the crash, of which 1,154 pounds would have been useable. It should be 

noted that these fuel burn calculations did not take into account unknown factors that could have 

altered the amount of fuel burned on any flight. For example, altitude changes, temperature 

variations, the use of engine bleed air and airplane configuration variations (such as landing gear 

extended) can affect fuel burn. 

Table 1. Estimated Fuel Remaining ñ High-Speed Cruise 

Date Flight Fuel 

added 

lbs.

Estimated 

departure 

fuel 

amount 

Departure 

fuel on 

load 

manifest 

Flight 

time in 

minutes 

Altitude Fuel burn 

per flight

Taxi time 

in minutes 

Taxi 

burn 

Fuel 

remaining 

lbs.

5/19 GON-PHF 985 3090 2900 96 16000 1090 12 72 1928 

5/19 PHF-FRG None 1928 NA 72 17000 792 12 72 1064 

5/20 FRG-ACY 800 1864 NA 30 4000 445 12 72 1347 

5/20 ACY-FRG None 1347 1400 30 5000 396 13 78 873 

5/20 FRG-ACY 676 1549 NA 36 4000 483 15 90 976 

5/20 ACY-AVP 1675 2651 NA 50 6000 662 13 78 1911 

5/20 AVP-ACY None 1911 2000 50 5000 677 15 90 1144 

5/20 ACY-FRG 409 1553 1500 37 5000 498 9 54 1001 

5/21 FRG-ACY 603 1604 2400 30 5000 401 13.5 est.29 81 1122 

5/21 ACY-AVP None 1122 NA 60 5000 847 6.5 est.30 48 275 

Table 2. Estimated Fuel Remaining ñ Long-Range Cruise 

Date Flight Fuel 

added 

lbs.

Estimated 

departure 

fuel 

amount 

Departure 

fuel on 

load 

manifest 

Flight 

time in 

minutes 

Altitude Fuel burn 

per flight

Taxi time 

in minutes 

Taxi 

burn 

Fuel 

remaining 

lbs.

5/19 GON-PHF 985 3090 2900 96 16000 941 12 72 2077 

5/19 PHF-FRG None 2077 NA 72 17000 655 12 72 1350 

5/20 FRG-ACY 800 2150 NA 30 4000 341 12 72 1737 

5/20 ACY-FRG None 1737 1400 30 5000 329 13 78 1330 

5/20 FRG-ACY 676 2006 NA 36 4000 402 15 90 1514 

5/20 ACY-AVP 1675 3090 NA 50 6000 542 13 78 2470 

5/20 AVP-ACY None 2470 2000 50 5000 563 15 90 1817 

5/20 ACY-FRG 409 2226 1500 37 5000 421 9 54 1751 

5/21 FRG-ACY 603 2354 2400 30 4000 419 13.5 est. 81 1935 

5/21 ACY-AVP None 1935 NA 60 5000 676 6.5 est. 39 1220 

 29 Because of the loss of the airplane log, which would have contained the taxi time for this flight, an average of 

the two previous fights that operated from FRG to ACY was used. The two previous flights used 12 minutes and 

15 minutes of taxi time. 30 Because of the loss of the airplane log, which would have contained the taxi time for this flight, the 13 

minutes of taxi time for a previous flight from ACY to AVP was used. This time was then divided in half to estimate 

the taxi out. 
22 

NTSB/AAB-02/05 

Simulator Observations 

Safety Board investigators conducted several Jetstream 31 simulator scenarios in 

June 2001 at Pan Am Flight Academy in Sterling, Virginia. The level C simulator was set to 

match as closely as possible the accident airplaneís configuration when the engines were lost. 

The simulator was operated at a simulated airplane weight of 13,500 pounds, which is the 

estimated weight of the accident airplane when it crashed. 

During the first simulated scenario, which was flown independently by two Safety Board 

pilots, a right engine failure was induced during an ILS approach, at an indicated airspeed of 

about 140 knots. A moderate amount of force on the rudder with rudder trim was sufficient to 

correct the resulting deviation. Any delay in flight control input led to heading deviations of 10° 

to 25° to the right of the ILS course. When deviations occurred, the airplane was easily 

controllable back to the ILS course. When the scenario was conducted with an airspeed of 

110 knots, considerably more rudder and rudder trim inputs were required to correct the 

deviations, keep the airplane on course, and turn back to the ILS. However, the airplane remained 

controllable. 

During the second simulator scenario, after a right engine failure was induced on an ILS 

approach (and after corrective rudder trim inputs were made), a left engine failure was induced. 

The simulated left engine failure was then allowed to operate as if the autolight system 

occasionally restored the engine briefly before failing again. In this scenario, the workload on the 

flying pilot was not considerably increased when the dual engine failure was induced. However, 

pilot workload increased considerably (the airplane was difficult to control and required constant 

flight control and trim inputs) when the left engine was intermittently lost and restored. 

Before the simulator sessions, instructors briefed both pilots that the low fuel quantity 

annunciator lights would be activated during the session but did not indicate when. Neither pilot 

observed the lights when they first appeared, and both pilots continued to fly without observing 

the lights. It was observed that the left seat pilotís right hand blocked a view of the lights when 

his right hand was on the control wheel. It was also observed that at certain seat positions, a 

portion of the control wheel blocked a clear view of these lights. It was also observed that the 

digital ìFUEL USEDî indicator lights located immediately above the low fuel quantity lights 

were much brighter in intensity than the low fuel quantity annunciator lights during simulated 

daylight and nighttime conditions. 

Engine and Propeller Teardown Examinations 

The engines were shipped in June 2000 to Honeywell Engines & Systems in Phoenix, 

Arizona, for a teardown inspection and evaluation under Safety Board supervision. Propeller 

assemblies were shipped to Dowty Aerospace Propellers in Sterling, Virginia, and were 

disassembled and examined under Safety Board supervision during the same period. 

The No. 1 engine showed rotational scoring between various rotating and static 

components, as well as metal spray on the turbine blades and vanes. The No. 2 engine was 
23 

NTSB/AAB-02/05 

heavily fire damaged and exhibited no rotational scoring between rotating and static components. 

Static impact marks were observed on the compressor impeller shrouds, and neither the turbine 

blades nor vanes exhibited any signs of metal spray. 

Disassembly of the left engine propeller hub revealed witness marks on the butts of three 

out of the four blades that were consistent with blade angles between 28° and 40°. The remaining 

blade revealed indications on the butts of two adjacent blades consistent with blade angles of 

approximately 80°. A feathered propeller is consistent with a minimum drag angle of 82°. The 

remaining two blades showed no discernible impact marks. 

Examination of ATC Audio Tape of Cockpit Transmissions 

The Safety Boardís audio laboratory examined a copy of the ATC tape recording of 

approach control and tower communications with the accident flight crew to identify and 

document engine or propeller sounds during the radio transmissions. The Safety Boardís 

examination assumed that the propeller normally rotates at a maximum speed of 1,591 rpm and 

that, at its maximum speed, the propeller would produce noise at the fundamental frequency of 

106.06 Hz. The examination concluded that the low frequency response of the pilotís headsets, 

the aircraftís radios and the approach controlís recording system were such that only the 

fundamental frequency of the rotating blades was recorded. The examination noted that none of 

the radio transmissions from the accident aircraft contained discrete frequency signatures that 

could be associated with the two rotating propellers. Several explanations could account for the 

lack of two sound signatures. Either both propellers were always operating at the same rpm, thus 

only producing one signature, or the recorded signature was being produced by only one of the 

two engines. However, the airplane is equipped with a system to closely match propeller rpm's. It 

was not possible to determine which of the aircraftís two engines was producing the noise that 

was observed on the recording or whether both engines were producing the noise. In addition, 

engine noise could not be conclusively identified in all radio transmissions. 

CVR Testing and Evaluation 

The CVR was examined at the manufacturerís facility in Sarasota, Florida. A standard 

bench check was conducted, and all components were found to be within the manufacturerís 

specifications. After installing a new tape, the recording capability of the CVR was tested, and it 

passed the standard bench check. The self-test and bulk-erase features were also tested and found 

to be within manufacturerís specifications. A bulk-erase trace signal was also identified on a 

second CVR of the same make and model after it was bulk erased, and the trace signals were 

identical. The presence of a bulk-erase trace signal was consistent with a CVR delivered from 

overhaul. There was no evidence of a 600 Hz self-test tone on the recording, which is recorded 

on the CVR tape when the self-test is activated in the cockpit as prescribed by the flight crew 

checklist. (See the CVR Maintenance section for details about the CVR operational test check.) 

After overhaul, the 600 Hz self-test tone is activated but is erased by the bulk-erase function. 
24 

NTSB/AAB-02/05 

COMPANY INFORMATION 

Company History 

East Coast Aviation Services was established in 1991. The company was previously 

known as Long Island Airlines and, prior to 1987, Montauk Caribbean Airways. Since 1991, the 

Part 135 on-demand charter operator has done business as Executive Airlines. The operation and 

all crews are based at FRG. At the time of the accident, Executive Airlines employed 10 pilots 

and operated 7 airplanes, 4 of which were Jetstream 31s. At the time of the accident, the director 

of operations had worked for the company for about 1 1/2 years, and the chief pilot had worked 

for the company for about 6 weeks. 

Executive Airlines had a contract with Caesarís Palace from November 1998 to 

November 1999. When the contract expired, the airline continued to fly trips for the casino on an 

ad hoc basis and also operated ad hoc flights for other casinos in Atlantic City. 

FAA records indicated that an Executive Airlines airplane was involved in an accident in 

1991 when engine failure forced a Piper PA-31-350 to ditch into the ocean 6 miles from John F. 

Kennedy airport in New York. The aircraft sank, but all airplane occupants were rescued. In 

addition, another Executive Airlines Piper PA-31-350 was involved in an incident when it 

experienced engine trouble on takeoff and returned for landing. 

MAINTENANCE 

General 

The FAA approved Executive Airlinesí maintenance program under air carrier certificate 

number ECAA477A. The company was authorized to use a continuous airworthiness 

maintenance program (CAMP) for its Jetstream aircraft, including the accident airplane. 

Executive Airlinesí CAMP manual, dated March 8, 2000, revision 5, provided for the following 

maintenance intervals: 

• ìService CheckîóEvery 7 calendar days 

• ìAî CheckóTo be performed at a time in service not to exceed 200 hours or 4 months 

• ìBî CheckóTo be performed at a time in service not to exceed 400 hours or 8 months 

• ìCî CheckóTo be performed each 12 months 

• ìDî CheckóTo be performed each 24 months 

• ìEî CheckóTo be performed each 48 months 

Executive Airlines documented its maintenance using a system of flight/maintenance log 

sheets and other records. According to the director of maintenance (DOM), logbook entries for 

each Jetstream were maintained in separate envelopes in the maintenance office. 

According to the accident airplaneís maintenance records, the right fuel quantity gauge 

was replaced in November 1999 after pilots reported that it fluctuated. The right fuel quantity 
25 

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gauge was replaced again in April 2000 after it was reported to have fluctuated. No unresolved 

discrepancies were noted for the engines, wings, fuel caps, or fuel tanks. 

CVR Maintenance 

According to the accident airplaneís maintenance records, a Fairchild A100A CVR was 

installed on the airplane on May 31, 1991, when the airplane was owned and operated by a 

Part 135 operator in Ohio. On July 3, 1998, Executive Airlines removed this CVR and installed a 

ìloanerî CVR into the accident airplane. The airplaneís flight/maintenance log indicated that the 

ìloanerî CVR was tested following installation. The log was marked with the statement, ìOps 

checked good.î On July 16, 1998, the ìloanerî CVR was removed and another CVR was 

reinstalled. The Discrepancy Correction sheet was marked with the following notation: ìOps 

Checked Good. No Defects Noted.î 

On June 29, 1999, an annual avionics inspection, which included the CVR, was 

performed by Duncan Avionics, an FAA-certified repair station. The aircraftís total time was 

about 13,462.3 hours. The CVR was also functionally checked during a ìCî check in 

August 1999 and the following remark was noted on the operatorís Discrepancy Correction 

Sheet: ìComplied with 12 mo F/C of CVR No defects noted.î 

On February 29, 2000, after a pilot reported that the CVR was inoperative, the CVR was 

removed and replaced. The airplaneís total time was 13,803.4 hours. The discrepancy for the 

removed CVR (serial number 58309) was described as ìBattery Weak Requires Replacement.î31

The original CVR was sent to a repair station, which determined that it was defective. 

The DOM indicated that on February 29, 2000, a serviceable CVR was installed in the 

accident airplane. This CVR was received after it was overhauled by a repair station. The 

accident airplaneís maintenance log indicated that the CVR was operationally checked and that 

no defects were noted. According to the DOM, the operational check was in accordance with the 

Executive Airlines maintenance program. 

The Safety Board reviewed all flight/maintenance logs between the date the accident 

CVR was installed in the airplane and May 20, 2000. (No maintenance logs were found dated 

May 21, 2000.) No evidence of CVR discrepancies or maintenance was noted for this period. The 

DOM stated that Executive Airlines maintained the CVR in accordance with the FAA-approved 

CAMP. Under this program, the CVR system was required to be maintained by performing 

checks at specific intervals. They included the following: 

• CVR Operational Check. This is a flight crew checklist item and is to be accomplished 

using the flight crew ìJ31 Preliminary Check List.î This check is to be performed by 

pressing the CVRís test button before the first flight of the day or whenever a crew 

 31 The only battery associated with the CVR is part of the underwater locator beacon, and the battery has no 

effect on the CVRís operation. 
26 

NTSB/AAB-02/05 

change occurs. The crew then monitors a test signal on a meter on the CVR control unit 

next to the test button. 

• Audio Interface Check. A complete audio interface testing procedure was described in the 

Fairchild installation manual, FAR02213189, and included plugging a headset into the 

control unit in the cockpit to test the systemís recording capability. According to the 

DOM, Executive Airlines did not perform a complete system interface test following the 

February 29, 2000, installation of the accident CVR because the CAMP did not require it 

following unscheduled maintenance.32

• Overhaul. The CVR manufacturer called for an overhaul to be completed every 

8,000 hours. Based on the accumulated hours on the accident CVR, it was not due to 

receive either a functional check or another overhaul. The DOM stated that CVR system 

repairs and functional checks were performed by contract avionics vendors. The DOM 

stated that Executive Airlines did not have a wiring diagram for the CVR system that was 

installed on the airplane. In addition, Executive Airlines did not have the FAA-approved 

Jetstream International Airlines, Inc., maintenance manual. According to the CVR 

installation documentation, the FAA required that the CVR system ìbe maintained in 

accordance with procedures contained in the FAA approvedî Jetstream manual. 

After the accident, L3 Communications, which acquired Fairchild, indicated that it would 

revise its CVR installation manual to add language specifying that a complete audio system 

interface test ìmust be completed during each annual inspection or specified maintenance period 

on the aircraft or rotorcraft and whenever unscheduled maintenance is performed on the aircraft 

or rotorcraft [that] may have affected the performance of the cockpit voice recorder system.î 

Before the accident, the language did not provide specific guidance about complete audio 

interface check intervals or the kinds of unscheduled maintenance that might affect the CVR 

system. 

Fuel Estimates Based on Fire Damage Evaluations 

According to a May 6, 2002, letter to the Safety Board, a fire consultant was engaged by 

Executive Airlines, to ìconduct a thorough analysis of the wreckageÖin order to determine the 

quantity of fuel on board at the time of this accident.î The consultantís report was submitted to 

the Safety Board on May 15, 2002. The report concluded that, ìbetween a minimum of 

41 gallons to a maximum of 163 gallonsî of fuel caused the thermal damage to the wings and 

fuselage between the engine nacelles and that a ìminimum of 1.6 gallons to a maximum of 

10.7 gallonsî of fuel caused the fire damage to the central region of the outboard left wing. The 

report added that ìno account has been made of fuel lost during the crash kinematics or of how 

much fuel could be absorbed by the crash terrain. For these reasonsÖthe amount of fuel released 

from the fuel cells during the crash would be more likely near the maximum quantities calculated 

by this analysis.î The consultantís report noted that ìsome of the damage to the upper fuselage 

 32 Following the accident, the operatorís CAMP was amended to require a CVR interface check during its 

service check and to require audio interface checks whenever CVR system components are ìinstalled or replaced.î 
27 

NTSB/AAB-02/05 

area probably resulted from the burning of cabin upholstery during the fireî but added that the 

damage ìwould be limited to materials above floor level.î 

The consultantís report was reviewed by fire experts at the FAA Technical Center in 

Atlantic City, New Jersey. The FAA review of this report, which was submitted to the Safety 

Board, noted that the fuel estimates in the consultantís report rely ìprimarily on an approximately 

10 square meter area between the enginesî to reach conclusions about the amount of fuel on 

board the airplane at the time of the accident. The FAA report concluded that the 10 square meter 

area ìused for the fuel quantity estimate should be reduced by half at a minimum to account for 

the contribution of cabin materials that make up 5 of the 10 square meter area. This would reduce 

the minimum estimate of fuel by half also, to 20.5 gallons.î The FAA report added that the 

ìcontribution of burning cabin materialsÖis likely much more than 5 square meters considering 

the radiation and convection from the burning cabin materials forward and aft of that section. 

After the fuselage skin melts, the wing root area on both sides of the fuselage would be exposed 

to the heat of the burning cabin materials.î The FAA report noted that other fuel sources, 

including hydraulic fluid and engine oil, were not considered in the consultantís report. The FAA 

report concluded that ìby ignoring the contribution of burning cabin materials and other fuel 

sources, the quantity of fuel estimated to produce all of the thermal damageÖis greatly 

overestimated.î 
28 

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ANALYSIS

GENERAL 

The captain and first officer were properly certificated and qualified in accordance with 

applicable Federal regulations and company requirements. Their duty time, flight time, rest time, 

and off-duty activity patterns did not indicate any preexisting medical, behavioral, or 

physiological factors that might have affected their performance on the day of the accident. 

Based on radar and AVP local and en route weather data, the accident airplane was in 

IMC during the entire flight from ACY to AVP and was in the clouds when the captain declared 

the missed approach at 1107:26. Weather data also indicate that the airplane remained in IMC 

(clouds and possibly occasional light rain) during the second approach (with intermittent ground 

visibility) until just before ground impact. Turbulence and/or airframe icing conditions were not 

factors in the accident. 

The airplane was properly certificated and equipped in accordance with Federal 

regulations and approved procedures. Passengers and fuel were properly loaded in accordance 

with FAA-approved company weight and balance procedures. The airplaneís weight and balance 

were within prescribed limits during all phases of the flight and were not factors in the accident. 

There was no indication of preexisting maintenance discrepancies that could have 

contributed to the accident. There were no pre-impact failures of any flight control system 

component. There were no pre-impact failures of any fuel system component to either engine, 

and no evidence of pre-impact engine damage. There was no evidence of an in-flight fire. 

A teardown examination of the No.1 (left) engine found rotational scoring and metal 

spray indicating that the engine was developing power at impact. An examination of the No. 2 

(right) engine, which found static imprints and no evidence of rotational scoring or metal spray, 

determined that the engine was not running at impact. 

All propeller blades were found at the crash site. The left engineís propeller blade angles 

were 28° to 40°, which is within the normal operating range, indicating that the engine was 

developing some power at impact. An examination of the right engineís propeller blades found 

angles of about 80°. This high blade angle is consistent with the right engine being in NTS and 

not developing power at impact. There was no evidence of any propeller anomalies. The fuel 

lines to each engine were intact and had no kinks or blockage that would have caused an 

interruption of fuel flow to the engines. The landing gear was extended at impact. 

The CVR did not record information during the accident flight and, based on subsequent 

testing, the Safety Board concluded that although the CVR was capable of recording information, 

it likely never operated. Bench testing indicated that the recorder was functional if properly 

installed, and a cockpit functional check should have indicated to flight crews that the CVR was 

not operating. The Safety Board could not determine why the system did not operate. The Safety 

Board notes that the lack of CVR information hindered the investigation and emphasizes the 
29 

NTSB/AAB-02/05 

Boardís position that functional onboard recording devices, including cockpit video recorders, 

are critical investigative tools. 

According to ACY-bound passenger statements, the captain had flown the first flight of 

the day from FRG to ACY. According to company practice, pilots alternated as the flying pilot 

on each leg. Further, representatives of the airline identified the captain as the pilot speaking with 

ATC in all radio transmissions. Thus, it is likely that the first officer was the flying pilot for the 

accident flight and may have remained in control of the airplane throughout the accident 

sequence. 

FLIGHT CREW ACTIONS 

The Missed Approach 

During the first ILS approach to runway 4 at AVP, the flight crew was advised by the 

AVP approach controller that a previous landing airplane had ìpicked up the airport at 

minimums.î Radar data indicated that the accident airplane had intercepted the ILS course and 

glideslope and descended along the glideslope and localizer to an altitude of about 2,200 feet msl 

when the airplane began to climb and the pilots advised the AVP tower that they were executing 

a missed approach. Radar data indicated that the airplane was level at 2,200 feet (about 1,000 feet 

above the decision altitude) for about 20 seconds and followed the center of the localizer before 

climbing about 700 feet to 2,900 feet before the pilots initiated the missed approach when they 

were within 2.2 nm of the runway threshold. 

Because the flight crewís cockpit conversation was not recorded and because the flight 

crew did not report the reason for the missed approach to controllers, the Safety Board could not 

conclusively determine why the missed approach was initiated. However, ATC tapes indicated 

no sense of urgency from the flight crew. Further, the flight crew accepted sequencing behind a 

slower airplane without advising the controller of a low fuel state or a desire to expedite the 

landing and flew a wide pattern to return to the localizer. Therefore, the Safety Board concludes 

that the flight crew was not aware of a potentially low fuel state or mechanical anomalies when 

the missed approach was executed. 

Loss of Directional Control 

ATC approach radar data indicated that the accident airplane deviated 55° in a right turn 

away from the localizer course during the second approach to AVP. Shortly after this deviation, 

the pilots informed the AVP controller that they were declaring an emergency because of engine 

failure. The deviation to the right was likely the result of asymmetrical thrust caused by stoppage 

of the right engine. Experiencing engine failure in IMC could cause pilots to fixate on 

instruments such as the attitude indicator and airspeed indicator and to allow the course heading 

to wander. However, during simulator tests, Safety Board investigators had minimal difficulty 

maintaining heading and controllability after a simulated right engine failure during approach to a 

landing. 
30 

NTSB/AAB-02/05 

The Safety Board notes that, based on the airplaneís performance capabilities and 

simulator tests, the accident airplane was controllable after the initial engine stoppage and its 

subsequent deviation from the ILS approach course should have been sufficiently correctable to 

enable the flight crew to execute a single-engine ILS approach and landing. Further, the Safety 

Board notes that during simulator tests, when a left engine failure was induced along with a 

failed right engine on an ILS approach, the airplane remained controllable with minimal 

difficulty. However, the airplane was more difficult to control and required constant flight 

control and trim inputs when the left engine was intermittently failed and restored.33 Because of 

impact damage to the empennage, and the stretching and twisting of the rudder trim control 

cables, an exact rudder trim position for the accident airplane could not be determined. 

The Safety Board also considered the possibility of a propeller governor malfunction. 

However, postaccident examinations determined that both propeller governors were functional. 

Further, had an internal governor failure occurred (such as a seized drive shaft), the loss of oil to 

the propeller dome would have caused the feathering spring to drive the propeller into feather 

and would not have caused significant control problems. 

Airplane Fuel Loading 

Three witness accounts provided information about how much fuel was on board the 

airplane at FRG before fuel was added in preparation for the first flight leg of the day to ACY: 

• The captain who cancelled the flight earlier in the day because of weather and because it 

was too late at FRG for the airplane to be refueled stated that the airplane had 

1,200 pounds of fuel on board; 

• The Executive Airlines owner and CEO stated that the accident first officer told him 

before departure that the fuel tank measuring sticks indicated that 1,100 pounds of fuel 

were on board; and 

• The first officerís fiancÈe, who was a passenger to ACY, stated that the first officer 

indicated that 1,200 pounds of fuel were on board and told her that one fuel gauge read 

300 pounds and that the other read 900 pounds. She stated that she believed that the 

300-pound indication was for the right tank. 

These reports are roughly consistent with Safety Board calculations, based on airplane log pages 

and flight crew records (between May 19 and before the accident airplaneís fueling in FRG), 

which indicated that about 1,000 pounds of fuel were onboard the airplane before the 600 pounds 

(90 gallons) were added on the day of the accident. 

 

33 The left engine failure was allowed to operate as if the autolight system occasionally restored the engine briefly 

before failing again. The Safety Board pilots were briefed that the simulated engine failures would occur but did not 

know when. 
31 

NTSB/AAB-02/05 

Statements from the carrierís owner and the first officerís fiancÈe and information from 

the weight and balance form completed by the accident crew suggest that the flight crew planned 

to add a total of 180 gallons to the airplane. If the flight crew intended to load 180 gallons (about 

1,200 pounds), it was common industry and company practice to ask for 90 gallons on each side. 

However, based on the evidence, it appears that a lack of clear communication between the pilots 

and the fueler resulted in only 90 gallons (about 600 pounds) of fuel being added, a total amount 

confirmed by the fuel order receipt. Further, it is likely that the flight crew did not confirm the 

amount of fuel loaded before departure because flight crews do not see the fuel receipts after 

fueling and because the pilots were not outside the airplane monitoring the fuel loading. 

The accident flight crew completed a load manifest that stated that the airplane was 

loaded with 2,400 pounds of fuel when it departed from FRG, and it is probable that the accident 

flight crew planned to depart from FRG with 2,400 pounds. Based on the airplaneís performance, 

2,400 pounds of fuel would have been sufficient fuel to fly the two flights without adding fuel 

during the stop at ACY. This would have allowed a takeoff from ACY that was within normal 

weight and balance limits for the airplane with 17 passengers on board. There was no evidence 

that the flight crew asked for additional fuel to be added during the stop at ACY. 

However, based on the Safety Boardís calculations, it appears that the accident airplane 

departed FRG with about 1,600 pounds of fuel on board, which is 800 pounds less than listed on 

the load manifest. Therefore, the Safety Board concludes that the accident airplane departed FRG 

with less fuel than the pilots thought they had on board. 

The accident pilots departed from FRG and ACY, completed two checklists (one for each 

of the flights) that included verification of fuel quantity,34 completed both load manifests for each 

of these flights (which required an entry indicating the amount of fuel on the airplane), and flew 

both flights apparently without being aware of a low fuel state. It is possible that the pilotsí belief 

that they had sufficient fuel on board for the flight to AVP caused them to be less vigilant in their 

monitoring of the airplaneís fuel state and slower to consider a low fuel state as the cause of the 

initial engine failure. Although low fuel quantity annunciator lights for each tank illuminate on 

the forward instrument panel when the fuel quantity decreases below 200 pounds, Safety Board 

investigators determined in simulations that these annunciator lights were easily overlooked, 

even when illuminated. Flight crews are required to constantly monitor their airplaneís fuel 

levels. If a pilot suspects that the fuel gauges are unreliable, fuel indicator sticks can be used to 

compare actual tank fuel levels to fuel gauge indications. Nevertheless, either pilot should have 

been able to determine a low fuel state by looking at the fuel gauges.35 Although the first officerís 

fiancÈe stated that the first officer was concerned about the accuracy of the airplaneís fuel 

gauges, her statements and those of the operatorís CEO indicated that the tank levels had been 

measured before the airplane was fueled at FRG. It is possible that the pilots discounted the 

accuracy of the fuel gauges in flight because they had measured the tanks and believed that they 

added sufficient fuel (180 gallons) for the dayís flights. Further, it is also possible that the pilots 

 34 The ìJ31 Preliminary Checklistî contains a ìFuel Quantityî check item and a ìlow fuel caution systemî test 

item. The ìBefore Takeoff Checklist,î from the ìJ31 Normal Checklist,î also has a fuel quantity check item. 35 The pilot who flew the accident airplane the day before stated that the fuel gauges were operating normally. 
32 

NTSB/AAB-02/05 

trusted and monitored the LED display showing fuel used.36 However, the Safety Board notes that 

this displayís accuracy is dependent on pilot input of the correct fuel quantity at the beginning of 

the flight. 

Engine Stoppage Scenarios 

The accident airplaneís estimated fuel burn was calculated using information provided by 

the airplane manufacturer, including the Jetstream 31 flight manual, and the operator. Fuel burn 

calculations were based on flight times entered into the airplaneís logbook. Based on calculations 

for high-speed cruise power settings37 (which included fuel load and fuel burn time estimates for 

taxi, climb, en route flight, and descent), the accident airplane could have had about 275 pounds 

of fuel on board when it crashed. If the airplane, in fact, had 275 pounds of fuel evenly 

distributed between the tanks at the time of the crash this would not explain the right engine 

stoppage and subsequent crash. However, several factors could affect the accuracy of the 

assumptions that were used in these calculations and, consequently, the reliability/accuracy of the 

275-pound result. 

Factors that can significantly change the amount of fuel burned on any flight include 

different (higher or lower) flight altitudes or airplane configurations, such as flaps and landing 

gear extended for long periods of time. Fuel burn is also increased during rapid, highperformance climbs, such as required for the execution of a missed approach. 

It is also possible that fuel load information for the accident airplane documented in the 

days before the accident did not accurately represent the airplaneís fuel load during this period. 

Carry-over errors in fuel load documents and differences in fuel calculations could result in 

assumptions of more fuel than was actually on board the airplane. For example, the Safety Board 

notes that its fuel calculations were based on the airplane being loaded to its maximum fuel load 

capacity, an amount that flight crews stated was rarely loaded. Using a 2,900-pound top-off fuel 

amount38 instead of the maximum 3,090 pounds (as assumed in the fuel burn calculations) for 

these instances resulted in only 85 pounds of fuel remaining. Assuming that as much as 

66 pounds were unusable, the remaining 19 pounds, or about 3 gallons, would have been enough 

for only about 1 to 4 minutes of flight. Therefore, assuming that these factors account for some or 

all of the fuel that would have remained under the conditions assumed for the high-speed cruise 

setting calculations and given the larger amount of fuel loaded in the left fuel tank, the right 

engine stoppage could be explained by fuel exhaustion.39 However, the Safety Board notes that 

 36 In a postaccident interview, the owner and CEO of Executive Airlines stated that the airlinesí pilots could 

determine current fuel loads by subtracting fuel burned from the known quantity at departure and that he believed 

that the fuel burned gauges are more reliable than the fuel quantity gauges. 37 Although Executiveís owner and CEO stated that flight crew used long range cruise settings, the Safety Board 

considered the airlineís director of operations to be more credible based on his direct interaction with line pilots as 

their supervisor and as a Jetstream 31 check captain and instructor. 38 As previously noted, Executive Airlines flight crews indicated that it was common practice to list 

2,900 pounds on the load manifest because tanks are rarely filled to the top. 39 Witness testimony indicated that the right tank contained less fuel when the airplane departed FRG. The 

airplaneís fuel crossfeed valve was found in the closed position. However, it was not possible to determine whether 

this valve was open before the accident (as is required by the airplane checklist in the event of an engine failure). 
33 

NTSB/AAB-02/05 

both the 275-pound and 85-pound flight time estimates indicate a critically low fuel state, and a 

fuel state well below the reserve required by the IFR flight plan filed by the flight crew. 

Further, the apparent difficulties with the left engine could be explained by unporting of 

whatever fuel remained in the left tank.40 Conditions would have been conducive to unporting if, 

for example, the airplane was in a left bank and in a nose-right sideslip following the loss of the 

right engine, which is consistent with flying straight while attempting to turn to the left, as 

indicated by the pilot statement ìweíre tryingî when the controller queried if the airplane was in 

a left turn. Assuming some usable fuel was in the left tank, it is probable that the flight crewís 

maneuvering after the right engine stoppage may have intermittently unported it, causing the 

sequential stoppage and restarting of the left engine. The Safety Board notes that the loss of the 

right engine occurred while the airplane was in relatively level flight and that the left engine 

stoppage occurred during attempts to maneuver back to the ILS course after the stoppage of the 

right engine. Further, the final loss of control may have been precipitated by momentary stopping 

or starting of the left engine when the airplane was at a reduced airspeed. Impact witness marks 

and airplane damage were consistent with a loss of control at low altitude. 

Observations made during examination of the accident site and the surrounding area were 

consistent with only a small amount of fuel being on board at the time of the crash. Severe fire 

damage was limited to the area immediately surrounding the crash site, suggesting a lack of 

significant fuel splash from the ruptured tanks. The burn pattern also indicated that there was 

little fuel remaining on board at impact. 

Fuel starvation to the engines caused by the failure of the LP fuel cock circuitry was also 

considered. However, no determination could be made because the LP fuel cock switches located 

in the cockpit were destroyed by impact and fire. The Safety Board notes that the right engine 

and left engine LP valves, which are controlled by the fuel cock circuitry, were found in the open 

position and that the hydraulic LP valves were found open. 

Loss of fuel en route was also considered. However, witnesses who observed the 

airplaneís departure from ACY saw no indication of leaking fuel from the wings or the fuel caps. 

Although the right tank fuel cap was not recovered, metallurgical evidence determined that it had 

been in place before impact. Further, the airplaneís manufacturer indicated that, because of the 

outboard location of the fuel caps, spillage or suction from an open fuel tank filler in level flight 

would be minimal and unlikely. 

Although the Safety Boardís fuel calculations do not demonstrate that the accident 

airplane was completely out of fuel, the Safety Board considered a critically low fuel state to be 

the most likely scenario given the lack of evidence indicating mechanical failures. Federal 

regulations and company policy state that it is the pilot-in-commandís responsibility to ensure 

before departure that the airplane has the correct amount of fuel onboard for the planned flight. 

The Safety Board concludes that because of miscommunication between the flight crew and the 

 40 Banking and acceleration can cause fuel to flow away, or become unported from, the airplaneís fuel pumps, 

which are located in the inboard section of the fuel tanks near the fuselage. 
34 

NTSB/AAB-02/05 

fueler about the amount of fuel to add at FRG and the flight crewís failure to ensure an adequate 

fuel supply, the airplane departed FRG with less fuel than the flight crewmembers stated on the 

load manifest and with less fuel than they believed they had. Further, the Safety Board concludes 

that the flight crewmembers failed to adequately monitor the airplaneís fuel state en route and at 

ACY based on the expectation that they had sufficient fuel on board to complete both flights. 

PROBABLE CAUSE 

The National Transportation Safety Board determines that the probable cause of this 

accident was the flight crewís failure to ensure an adequate fuel supply for the flight, which led 

to the stoppage of the right engine due to fuel exhaustion and the intermittent stoppage of the left 

engine due to fuel starvation. Contributing to the accident were the flight crewís failure to 

monitor the airplaneís fuel state and the flight crewís failure to maintain directional control after 

the initial engine stoppage. 

Adopted on August 26, 2002