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Aircraft Accident Report

In-Flight Engine Failure and Subsequent 

Ditching

Air Sunshine, Inc., Flight 527 

Cessna 402C, N314AB

About 7.35 Nautical Miles West-Northwest of 

Treasure Cay Airport, Great Abaco Island, 

Bahamas

July 13, 2003

NTSB/AAR-04/03

PB2004-910403 National Transportation Safety Board

Notation 7671A 490 LíEnfant Plaza, S.W.

Adopted October 13, 2004 Washington, D.C. 20594

E PLUR IBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N
National Transportation Safety Board. 2005. In-Flight Engine Failure and Subsequent Ditching, Air

Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35 Nautical Miles West-Northwest of

Treasure Cay Airport, Great Abaco Island, Bahamas, July 13, 2003. Aircraft Accident Report

NTSB/AAR-04/03. Washington, DC.

Abstract: This report explains the accident involving Air Sunshine, Inc., flight 527, a Cessna 402C,

which experienced an in-flight engine failure and was subsequently ditched about 7.35 nautical

miles west-northwest of Treasure Cay Airport, Great Abaco Island, Bahamas. The safety issues

discussed in this report include maintenance record-keeping and practices, pilot proficiency,

Federal Aviation Adminstration (FAA) oversight, and emergency briefings. A safety

recommendation concerning emergency briefings is addressed to the FAA.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2004-910403 from:

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Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Aircraft Accident Report

Contents

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.1 The Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.1.1 Flight Check History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.5.2 The Director of Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.5.3 The Assistant Mechanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.6.1 Engines and Propellers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.6.1.1 Air Sunshine’s Approved Aircraft Inspection Program. . . . . . . . . . . . . . . . . . . . 10

1.6.1.2 Differential Compression Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.6.1.2.1 June 12 to 14, 2003, Differential Compression Checks . . . . . . . . . . . . . . . . 12

1.6.1.3 Time Between Overhauls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12.2 Engines and Propellers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.15.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.15.2 Emergency Briefings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.15.3 Personal Flotation Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.15.4 Search and Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.16.1 Cessna Airplane Performance Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.16.2 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1.16.3 Metallurgical Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.16.3.1 Right Engine Cylinder Assemblies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.16.3.2 Right Engine Pistons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.16.3.3 Right Engine Crankcase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Contents iv Aircraft Accident Report

1.16.3.4 Right Engine No. 2 Cylinder Hold-Down Studs and Through Bolts . . . . . . . . . 27

1.16.3.5 Cylinder Hold-Down Nuts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.17.1 Air Sunshine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.17.1.1 Air Sunshine’s In-Flight Engine Failure Procedures. . . . . . . . . . . . . . . . . . . . . . 30

1.17.1.2 Ditching Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.17.1.3 Company Record-Keeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.17.1.3.1 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1.17.1.3.2 Aircraft Flight Logs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.2 Federal Aviation Administration Oversight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.2.1 General. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.2.2 San Juan Flight Standards District Office Preaccident 

Oversight of Air Sunshine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.17.2.3 Fort Lauderdale Flight Standards District Office 

Postaccident Oversight of Air Sunshine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.17.2.4 San Juan Flight Standards District Office Postaccident 

Oversight of Air Sunshine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

1.17.2.5 Additional Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.18.1 Previous Ditching Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2.3 Airplane Performance After the Right Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.4 Right Engine Failure Sequence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

2.5 Cause of the Loosened No. 2 Cylinder Hold-down Nuts . . . . . . . . . . . . . . . . . . . . . . . . 40

2.6 Air Sunshine Maintenance Record-Keeping and Practices . . . . . . . . . . . . . . . . . . . . . . 41

2.7 Pilot Proficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

2.8 Pilot Failure to Use Shoulder Harness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

2.9 Emergency Briefings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

4. Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

5. Appendix 

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
v Aircraft Accident Report

Figures

1. Interior configuration of the accident airplane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2. Cylinder differential compression check form.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

3. Exterior of the upper outboard engine cowling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4. The condition in which the right engine No. 2 cylinder 

retention system components were found. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
vi Aircraft Accident Report

Abbreviations

A&P airframe and powerplant

AAIP Approved Aircraft Inspection Program

ARTCC air route traffic control center

ATP airline transport pilot

CFI certified flight instructor

CFR Code of Federal Regulations

CG center of gravity

CVR cockpit voice recorder

F Fahrenheit

FAA Federal Aviation Administration

FDR flight data recorder

FLL Fort Lauderdale/Hollywood International Airport

fpm feet per minute

FSDO Flight Standards District Office

Hg mercury

KIAS knots indicated airspeed

METAR meteorological aerodrome report

MYAT Treasure Cay Airport

MYGF Grand Bahamas International Airport

PFD personal flotation device

PIC pilot-in-command

PMI principal maintenance inspector

psi pounds per square inch

PTRS Program Tracking and Recording System

SB service bulletin

SJU Luis Munoz Marin International Airport

SRQ Sarasota/Bradenton International Airport

TBO time between overhaul

TCM Teledyne Continental Motors

TSO Technical Standard Order
vii Aircraft Accident Report

Executive Summary

On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing

business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was

ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay

Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, following the in-flight

failure of the right engine. Four of the nine passengers sustained no injuries, three

passengers and the pilot sustained minor injuries, and one adult and one child passenger

died after they evacuated the airplane. The airplane sustained substantial damage. The

airplane was being operated under the provisions of 14 Code of Federal Regulations

Part 135 as a scheduled international passenger commuter flight from Fort

Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida, to MYAT. Visual

meteorological conditions prevailed for the flight, which operated on a visual flight rules

flight plan.

The National Transportation Safety Board determines that the probable cause of

this accident was the in-flight failure of the right engine and the pilotís failure to

adequately manage the airplaneís performance after the engine failed. The right engine

failure resulted from inadequate maintenance that was performed by Air Sunshineís

maintenance personnel during undocumented maintenance. Contributing to the passenger

fatalities was the pilotís failure to provide an emergency briefing after the right engine

failed.

The safety issues discussed in this report include maintenance record-keeping and

practices, pilot proficiency, Federal Aviation Administration (FAA) oversight, and

emergency briefings. A safety recommendation concerning emergency briefings is

addressed to the FAA. 

1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On July 13, 2003, about 1530 eastern daylight time,1 Air Sunshine, Inc. (doing

business as Tropical Aviation Services, Inc.),2 flight 527, a Cessna 402C, N314AB, was

ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay

Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, after the in-flight failure of

the right engine. Two of the nine passengers3 sustained no injuries, five passengers and the

pilot sustained minor injuries, and one adult and one child passenger died after they

evacuated the airplane.4 The airplane sustained substantial damage. The airplane was

being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as

a scheduled international passenger commuter flight from FLL to MYAT.5

 Visual

meteorological conditions prevailed for the flight, which operated on a visual flight rules

flight plan.

The accident pilot was scheduled to fly the accident airplane on a 2-day trip

sequence, which began about 0900 on July 12, 2003. The pilot flew five flights, each of

which lasted about 1 hour, on the first day of the trip sequence. The last flight was from

FLL to Sarasota/Bradenton International Airport (SRQ), Sarasota, Florida, and it arrived

at SRQ about 1930. All of the first dayís flights were uneventful, and the pilot reported no

engine- or airframe-related discrepancies for any of the flights. 

On July 13, 2003, the pilot arrived at SRQ about 0830 for the second day of the

trip sequence. The pilot was scheduled to conduct five flights, each of which was to last

about 1 hour. The first flight departed SRQ about 0930 and arrived at FLL about 1030.

The second flight departed FLL about 1100 and arrived at MYAT about 1200. The third

1 Unless otherwise indicated, all times in this report are eastern daylight time. The airplane was not

equipped with a cockpit voice recorder (CVR) and was not required to be so equipped. Therefore, all times

referenced in this report are approximations, except for the takeoff time, which was determined by reference

to transcripts of voice recordings obtained from the Fort Lauderdale/Hollywood International Airport (FLL)

air traffic control tower and the Miami Automated International Flight Service Station. 

2 Air Sunshine and Tropical Aviation Services are two separate companies owned and operated by the

same people. 

3 Four of the nine passengers were children; one of the children was under 2 years of age and was

seated on an adult passengerís lap during the flight. 

4 The search for, and rescue of, the surviving airplane occupants (and recovery of the bodies of the two

other airplane occupants) is discussed in section 1.15.4.

5 Under the provisions of Annex 13 to the Convention on International Civil Aviation, the

investigation of an airplane crash is the responsibility of the state of occurrence (the state or territory in

which an accident or incident occurs, which in this case was the Bahamas). However, the state of occurrence

may delegate all or part of an investigation to another state by mutual arrangement or consent. At the request

of the Bahamian Government, the National Transportation Safety Board assumed full responsibility for the

investigation. The Bahamian Government designated an accredited representative to the investigation.
Factual Information 2 Aircraft Accident Report

flight departed MYAT about 1215 and arrived at FLL about 1330. All of the flights were

reported to be uneventful. 

The pilot stated that, before departing on the fourth flight of the day, from FLL to

MYAT, he conducted a preflight inspection of the airplane, which included checking the

oil quantity. The accident flight was cleared for takeoff at 1427:11 and was estimated to

last about 1 hour 10 minutes.

During postaccident interviews, passengers stated that, before starting the engines,

the pilot briefed6 them on the location of the personal flotation devices (PFD),7 the exits,

and the safety briefing cards8

 and on the need to keep their lapbelts fastened during the

flight. One of the passengers who accompanied a child noted that the pilotís briefing did

not include how to handle children during an emergency and added that the briefing was

ìshort and rushed.î

The pilot and adult passengers stated that the cruise portion of the flight was

uneventful, and the pilot stated that the engine instruments showed no indications of a

mechanical problem. The pilot indicated that the flightís cruise altitude was about

7,500 feet and that the cruise speed was about 160 knots indicated airspeed (KIAS).9

The pilot stated that, during the descent into MYAT, he maintained the same power

setting that he used during cruise flight, which was about 2,300 rpm and 27 inches of

mercury (Hg) manifold pressure. The pilot stated that, about 20 to 25 miles from MYAT

(about 45 to 50 minutes into the flight), while descending to about 3,500 feet, he heard a

bang and saw oil coming out of the right engine cowling.10

The adult passenger in the copilotís seat (the seat to the right of the pilot seat)

reported seeing a ìstream of oilî coming from the right engine and stated that he notified

the pilot of his observation. Several of the other adult passengers reported seeing white

smoke coming from the right engine. These passengers stated that the smoke was followed

6 Title 14 CFR 135.117(a) requires pilots to brief passengers orally before departure.

Section 135.117(a) states that the predeparture briefing should include, in part, information on the use of

safety belts, the location of and instructions for opening the passenger entry door and emergency exits, and

the location of survival equipment. 

7 The airplane was equipped with 10 PFDs that were sealed in plastic pouches. Eight of the PFDs were

stowed under the forward edge of each passenger seat. The PFDs for the pilot and copilot positions were

stowed outboard of each pilot seat. For more information, see section 1.15.3.

8 The safety briefing cards were contained in the stowage pockets located on the back of each seat. 

9 The airplane was not equipped with a flight data recorder (FDR) and was not required to be so

equipped. Data from the Nassau Air Route Surveillance Radar (about 125 miles south of the accident

site) did not indicate any targets in the Bahamas airspace consistent with the reported route and altitude of

flight 527. Other aircraft were observed at an altitude of about 6,600 feet and above near Grand Bahamas

Island and at an altitude of about 5,100 feet and above near the ditching site. All flight altitudes and speeds

referenced in the report are based on the pilotís recollections. 

10 From June 12 to 14, 2003, Air Sunshineís Director of Maintenance and an assistant mechanic

performed differential compression checks on the accident airplaneís right engine cylinders during the

airplaneís last recorded engine maintenance. For more information about these checks, see section 1.6.1.2.1.
Factual Information 3 Aircraft Accident Report

by a stream of oil and then the sound of a loud bang. They reported seeing parts falling

from the engine after they heard the loud bang. 

The pilot stated that, after he heard the bang, he reduced power to the right engine.

The pilot indicated that, at the time of the event, the airplaneís airspeed was about 135 to

140 KIAS. He added that the airspeed for a normal descent should be about 140 knots.

The pilot stated that he then saw that the engine magnetos had penetrated through the

engine cowling and that the magnetos were hanging from wires. He added that he did not

see any other damage. He stated that he noticed that the right engine oil pressure

indication was decreasing rapidly. He added that the fuel selector was ìin the greenî (that

is, each engine was being provided fuel from its respective main fuel tank). He stated that

he attempted to feather11 the right propeller and shut down the engine12 but that the

propeller continued ìwind-millingî (turning) slowly. The passenger in the copilot seat and

the adult passenger in the seat behind the copilotís seat also reported that the pilot tried to

feather the right propeller but that it continued to turn after the engine failed.13

The pilot stated that, after he attempted to shut down the right engine, he applied

full power to the left engine and tried to fly the airplane but that he could not maintain

altitude. He stated that he slowed the airplane to ìblue lineî (single-engine best climb rate)

airspeed, which is about 105 KIAS, and that, at that point, the airplane was at a descent

rate of about 200 to 300 feet per minute (fpm). 

The pilot stated that he contacted Air Sunshineís station manager at MYAT after

trying to shut down the engine. The station manager stated that the pilot told him that the

right engine had failed and that he was at an altitude of about 3,000 feet. The manager

added that the pilot asked him to contact the companyís Director of Operations at FLL,

which the manager did. Air Sunshineís Director of Operations told the manager to ask the

pilot if the propeller on the failed engine was feathered, and the pilot responded that it

was. The Director of Operations then asked the manager to get the airplaneís distance

from the airport, altitude, and descent rate; the pilot responded that he was about 15 miles

from the airport14 at an altitude of about 2,000 feet with a descent rate of about 200 fpm.

The Director of Operations instructed the manager to tell the pilot to ìkeep the good

engine at full power, bank to the good engine and to just stay calm and fly the plane.î The

pilot told the manager that he had already ìdone all of those things.î

11 Feathering means to rotate the propeller blades so that the blades are parallel to the line of flight to

reduce drag and prevent further damage to an engine that has been shut down.

12 The pilot stated that he did not follow Air Sunshineís procedures for an in-flight engine failure

because he knew which engine had failed; therefore, he chose to immediately shut down the right engine. He

added that he did not follow the engine failure checklist because he was ìtoo busy flying the airplane.î For

more information about Air Sunshineís in-flight engine failure procedures, see section 1.17.1.1.

13 The pilot and both passengers reported that the right propeller continued turning until the airplane

contacted the water.

14 The airplane was equipped with a global positioning system, which the pilot used to determine the

airplaneís distance from the airport.
Factual Information 4 Aircraft Accident Report

The station manager stated that he then alerted local agencies about the emergency

and instructed another Air Sunshine pilot, who had just taken off from Marsh Harbor,

Bahamas, for FLL, to divert that flight toward flight 527 and follow the airplane until it

reached the airport. The Air Sunshine pilot transmitted a distress call for flight 527, which

the pilot of a nearby flight (Gulf flight 9267) heard and relayed to the Federal Aviation

Administration (FAA) Air Route Traffic Control Center (ARTCC), Miami, Florida.

The pilot stated that, after talking to the station manager, he slowed the airplane to

about 95 KIAS to try to maintain altitude. The pilot stated that, once he descended from

about 1,500 to 1,000 feet, he realized the airplane could not make it to the airport and that

he would have to ditch the airplane. The pilot stated that he ditched the airplane parallel to

the waves with the flaps retracted. He added that, at the time of the ditching, the winds

were about 15 knots, and the outside air temperature was about 80° to 90° Fahrenheit (F).

The passenger in the copilot seat stated that the pilot did a good job ditching the airplane.

He stated that he noticed a placard on the instrument panel with instructions for ditching,

which stated that the airspeed should be kept in the ìblue zone,î and that the airspeed was

within this zone during the ditching. Adult passengers described the contact with the water

as ìvery hard.î They stated that the airplane landed ìflatî and that it did not dive into the

water. 

During postaccident interviews, the passengers stated that the pilot did not instruct

them to retrieve their PFDs or to assume a brace position before contact with the water.

The passengers stated that the only time the pilot addressed them after the right engine

failed and before the airplane contacted the water was to tell them to ìcalm down.î

The airplane was located at 26° 45.547' north latitude and 77° 31.642' west

longitude. The accident occurred during daylight hours. 

1.2 Injuries to Persons

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 0 0 2 02

Serious 0 0 0 00

Minor 1 0 5 06

None 0 0 2 02

Total 1 0 9 0 10
Factual Information 5 Aircraft Accident Report

1.3 Damage to Airplane

The airplane sustained substantial damage. 

1.4 Other Damage

No other damage was reported.

1.5 Personnel Information

1.5.1 The Pilot

The pilot, age 46, was hired by Air Sunshine in September 1995. He held an airline

transport pilot (ATP) certificate, which was issued March 7, 1998, with a multiengine land

rating. Additionally, he held a commercial pilot certificate with a single-engine land rating

and a certified flight instructor (CFI) certificate with single-engine, multiengine, and

instrument ratings. The pilot held an FAA first-class medical certificate, dated June 9,

2003, with no limitations.

According to the pilot, he began flight training at Aviation Training, Hayward,

California. The pilot reported that, before he began working for Air Sunshine, he worked as a

first officer on Embraer 110 airplanes for Payam Aviation Services, Tehran, Iran, for 2 years. 

The pilot began working for Air Sunshine in September 1995, performing clerical

work for about 6 months before starting the companyís flight training. He served as first officer

on the companyís Embraer 110 for about 1 1/2 years, during which time he earned his ATP

certificate. In 1998, he upgraded to captain on the Cessna 402. He resigned from Air Sunshine

on September 29, 2002. From September 30 to November 11, 2002, the pilot received flight

training at Arrow Air, Inc., in Miami.15 The pilot left Arrow Air because he could not

complete the training.16 On November 23, 2002, the pilot was rehired by Air Sunshine.

Air Sunshine records indicated that the accident pilot had accumulated a total

flying time of about 8,000 hours, about 5,500 hours of which were as pilot-in-command

(PIC) and about 5,000 hours of which were in Cessna 402 airplanes. He had flown

about 251, 69, 13, and 6 hours in the last 90, 30, and 7 days, and 24 hours, respectively.

The pilotís last PIC line check occurred on July 9, 2002; his last PIC proficiency check

occurred on January 14, 2003; and his last recurrent ground training occurred on June 14,

2003. A search of FAA records found no evidence of enforcement actions.

15 Arrow Air is a 14 CFR Part 121 supplemental all-cargo air carrier. During the time that the pilot was

in training, the company operated McDonnell Douglas DC-8 and Lockheed L-1011 airplanes.

16 A review of Arrow Airís simulator training records for the pilot revealed that he had received a large

number of ìunsatisfactoryî grades. Further, the records indicated that the pilot needed to improve his

scanning and checklist skills, including response and organization. 
Factual Information 6 Aircraft Accident Report

FAA records revealed that the pilot had been involved in an incident on June 12,

1999, in which the nose landing gear collapsed during landing at FLL. The pilot and

passengers were not injured, and the airplane sustained minor damage. The records also

revealed that the pilot was involved in an accident on March 16, 2000, in which a tire

failed during takeoff from FLL.17 The pilot aborted the takeoff but was unable to keep the

airplane on the runway. The pilot and passengers were not injured, and the airplane

received substantial damage. Further, a review of the FAAís Program Tracking and

Reporting System (PTRS) records revealed that, on September 13, 2000, the pilot failed a

ramp check because his airplane was found to have numerous discrepancies and his

passenger briefing was found to be inadequate.

As previously stated, the pilot was scheduled for a 2-day trip sequence on July 12

and 13, 2003. Between 0900 and 1700 on July 12th, the pilot flew five flights and

accumulated about 5 hours of flight time. All of the flights were conducted in the accident

airplane. The pilot stated that, after the last flight (FLL to SRQ), he ate, watched some

television, and went to bed between about 2230 and 2300. 

The pilot stated that he awoke about 0730 on July 13th and arrived at SRQ

about 0830 to report for the second day of the trip sequence, which consisted of five

scheduled flights starting about 0930. Each flight was expected to last about 1 hour. The

pilot completed three of the scheduled flights before the accident flight occurred.

1.5.1.1 Flight Check History

Between April 1983 and February 1998, the pilot received the following notices of

disapproval from the FAA:

ï In April and May 1983, the pilot received notices of disapproval because he

failed the entire flight test portion of the flight checks18 he was receiving for

his private pilot certificate. On June 22, 1983, the pilot was rechecked

successfully, and he received his private pilot certificate. 

ï On October 30, 1985, the pilot received a notice of disapproval because he

failed the ìholdingî and the ìrecovery from an unusual attitudesî portions of

the flight check he was receiving for his instrument rating. On November 8,

1985, the pilot was rechecked successfully, and he received his instrument

rating.

ï In December 1987 and February 1988, the pilot received notices of disapproval

because he failed the entire flight test portion of the flight checks he was

receiving for his CFI certificate. On March 17, 1988, the pilot was rechecked

successfully, and he received his CFI certificate.

17 A description of this accident, MIA00LA109, can be found on the Safety Boardís Web site at

<http://www.ntsb.gov>.

18 If a pilot receives a notice of disapproval for a flight check, the pilot can be required to be rechecked

on the complete flight check or on designated portions of the flight check. 
Factual Information 7 Aircraft Accident Report

ï In July 1988 and May 1989, the pilot received notices of disapproval because

he failed the entire flight test portion of the flight checks he was receiving for

his CFI instrument rating. In August 1989, he received another notice of

disapproval because he failed the ìholdingî portion of the flight check and did

not complete three other portions of the check. On December 8, 1989, the pilot

was rechecked successfully, and he received his CFI instrument rating.

ï In February 1998, the pilot received a notice of disapproval because he failed

the ìnondirectional beacon approachî portion of the flight check he was

receiving for his ATP certificate. On March 7, 1998, the pilot was rechecked

successfully, and he received his ATP certificate. 

1.5.2 The Director of Maintenance

Air Sunshineís Director of Maintenance was hired by the company in March 1997

as a mechanic; seven months later, he was promoted to Director of Maintenance. 

On October 28, 1989, the Director of Maintenance applied for his airframe and

powerplant (A&P) certificate based on work experience19 he obtained while working as an

assistant mechanic from March 1985 to the date of the application. On October 24, 1990, the

director took the oral and practical examinations required by 14 CFR 65.79.20 He passed all

of the oral examinations; however, he failed the following portions of the practical exam:

Section I, General ñ Airframe and Powerplant, subsections (A) weight and balance and

(B) completion of FAA Form 337; and Section IV, Powerplant Theory and Maintenance,

subsection (A) troubleshooting of turbine engines. The director received additional training

in these areas and retook the practical exam on October 30, 1990, at which time he received

his A&P certificate. A search of FAA records found no evidence of enforcement actions.

The Director of Maintenance reported that, from March 1985 to August 1990, he

worked as an assistant mechanic on Cessna 402 airplanes at Airways International, a

14 CFR Part 135 on-demand charter operator in Miami. From January 1988 to March 1989,

he also worked part-time as an assistant mechanic on McDonnell Douglas DC-10 and

Lockheed L-1011 airplanes at Eastern Airlines in Miami. From mid-1990 to mid-1996, he

worked as a mechanic at Airways International. From August 1996 to March 1997, he

worked as a mechanic on Cessna 402, 210, and 206; Piper Cherokee; Britten-Norman

Islander; and Beechcraft 55 and 58 airplanes at Flightline of America, Pembroke Pines,

Florida.

19 According to 14 CFR 65.77, ìExperience Requirements,î ìeach applicant [for a mechanic certificate or

rating]Ömust present either an appropriate graduation certificate or certificate of completion from a certificated

aviation maintenance technician school or documentary evidence ofÖat least 30 months of practical experience

concurrently performing the duties appropriate to both the airframe and powerplant ratings.î

20 According to 14 CFR 65.79, ìSkill Requirements,î ìeach applicant [for a mechanic certificate or

rating]Ömust pass an oral and a practical test on the rating he seeks. The tests cover the applicantís basic skill in

performing practical projects on the subjects covered by the written test for that rating. An applicant for a

powerplant rating must show his ability to make satisfactory minor repairs to, and minor alterations of,

propellers.î
Factual Information 8 Aircraft Accident Report

1.5.3 The Assistant Mechanic

Air Sunshineís assistant mechanic was hired by the company on June 6, 2000, to

work in San Juan, Puerto Rico. In March 2003, he transferred to the companyís facility at

FLL. The assistant mechanic did not have an A&P certificate. 

On March 31, 2003, the Director of Maintenance signed off a Certificate of

Training for the assistant mechanic, indicating that he had completed 30 hours of basic

indoctrination training. On April 30, 2003, the director signed off a Certificate of Training

for the assistant mechanic, indicating that he had completed 60 hours of aircraft subjects

training. On June 30, 2003, the director signed off a Certificate of Training for the

assistant mechanic, indicating that he had completed 200 hours of on-the-job training for

the ìentire aircraft, airframe, engine, propeller, accessories, etc.î 

1.6 Airplane Information

The accident airplane, serial number 402C0413, was manufactured by Cessna

Aircraft Company on November 24, 1980. The airplane was operated by several airlines21

before being sold to Tropical International Airlines, Inc.,22 on August 29, 1997. From

mid-1997 to late 2000, the airplane was kept at the companyís maintenance facility at FLL.

Air Sunshineís President stated that, during this time, extensive maintenance was being

performed on the airplane, including left and right engines and propellers replacement, sheet

metal repair, corrosion treatment, and landing gear repair, to make it airworthy.

Tropical International Airlines leased the airplane to Air Sunshine on November 1,

2000.23 The airplane was inspected in accordance with Air Sunshineís FAA Approved

Aircraft Inspection Program (AAIP) on November 20, 2000, and found to be airworthy.24

The airplane was added to the companyís operations specifications on December 6, 2000.

The airplane was configured with a pilot seat (left side), a copilot seat (right side),

and eight passenger seats. (See figure 1.) The airplane was equipped with a window

escape hatch adjacent to the pilot seat (1A); an emergency escape hatch adjacent to seats 2B

and 3B; and a two-section outward opening airstair door (main cabin door) adjacent to

seats 4A and 5A, the lower portion of which was equipped with stairs. The pilot and

copilot seats were equipped with lapbelts and single-strap shoulder harnesses, and the

passenger seats were equipped with lapbelts. 

21 On March 1, 1992, the airplane was involved in a nose landing gear collapse while being operated by

Airways International. For more information about this accident, MIA92IA090, see the Safety Boardís Web

site at <http://www.ntsb.gov>.

22 Tropical International Airlines was owned and operated by the same people who own and operate Air

Sunshine.

23 The lease agreement stated that Air Sunshine would be responsible for all expenses, including

maintenance.

24 For more information about Air Sunshineís AAIP, see section 1.6.1.1
Factual Information 9 Aircraft Accident Report

According to the load manifest form for the accident flight, the airplaneís takeoff

weight was about 6,644 pounds, including 890 pounds of passenger weight,25 350 pounds

of baggage weight, and 800 pounds of fuel weight. The airplaneís takeoff center of gravity

(CG) was 154.61 inches aft of the reference datum. After the airplane was retrieved from

the water,26 the baggage was removed from the airplane, dried, and weighed. The baggage

weighed 440.85 pounds, 90 pounds more than the amount that was entered on the load

manifest form. After applying the additional 90 pounds, the weight and CG were still

within acceptable limits.27 

1.6.1 Engines and Propellers

The airplane was equipped with two Teledyne Continental Motors (TCM)

TSIO-520-VB reciprocating engines. These engines are turbo-charged and fuel-injected

with six horizontally opposed air-cooled cylinders. The engines are rated for 325 horsepower

at a power setting of 2,700 rpm with 39 inches Hg manifold pressure up to an altitude of

12,000 feet. 

Figure 1. Interior configuration of the accident airplane.

25 Actual passenger weights were used to calculate the total passenger weight.

26 The airplane was retrieved from the water on August 3, 2003. The retrieval was delayed because of

choppy waters.

27 According to the Cessna 402C Pilot Operating Handbook, the airplaneís maximum gross takeoff

weight is 7,210 pounds, and the maximum gross landing weight is 6,850 pounds. The maximum forward CG

for flight 527 was 151.2 inches aft of the reference datum, and the maximum aft CG for the flight was

160.7 inches.
Factual Information 10 Aircraft Accident Report

The engine cylinders incorporate an overhead inclined valve design. The cylinders

have updraft intake inlets and downdraft exhaust outlets mounted to the underside of the

cylinder heads. Each of the six cylinders is attached to the engine case by a series of

threaded studs, through bolts, and nuts. Six 7/16-inch, 20 threads-per-inch studs are

threaded into the case half for exclusive use at each cylinder location and are held down

by 6-point nuts. Additional studs are positioned between the cylinders and are shared by

adjacent cylinders. Two 1/2-inch through bolts, which are located at the engine crankshaft

main bearing positions, are either shared by opposed cylinders or the opposite crankcase

half and are held down by 12-point nuts. 

The right engine, serial number 529092, and the left engine, serial

number 811069-R, were manufactured by TCM on February 1, 1991, and January 1, 1997,

respectively. Airmark Overhaul, Inc., in Fort Lauderdale28 overhauled the right and left

engines on December 14 and December 21, 1999, respectively.29 At the time of overhaul,

the right and left engines had times since new of 3,582.6 flight hours and 2,400.0 flight

hours, respectively. The right and left engines were installed on the accident airplane on

October 10 and 7, 2000, respectively. The last routine engine maintenance, which included

changing the oil, inspecting the oil filter, looking for leaks, and performing a ground

run-up, was conducted on July 8, 2003, and the time since overhaul for both engines at

that time was 2,246.5 flight hours. At the time of the accident, both engines had a time

since overhaul of 2,270.6 flight hours.30

The airplane was equipped with two McCauley Propeller Systems 3AF32C505-C

three-bladed, dual-acting, constant-speed propellers. The blades are counterweighted to

help move them toward higher blade angles (that is, toward feather) during operation.

A feather spring inside the propeller moves the blades to the high-pitch (feather) stops.

A centrifugal start-lock system, which uses spring-loaded pins that engage the piston as

the propeller speed drops below approximately 600 rpm, prevents the blades from

traveling all the way to feather during normal engine shutdowns, which reduces the load

on the engine during subsequent engine starts.

1.6.1.1 Air Sunshineís Approved Aircraft Inspection Program

As a 14 CFR Part 135 operator, Air Sunshine had the option to operate either under

the manufacturersí maintenance inspection programs or to develop and receive FAA

approval for its own maintenance inspection program. From 1982 to 1992, Air Sunshine

operated under the manufacturersí (Cessna, TCM, and McCauley Propeller) maintenance

inspection programs.

In early 1992, under the oversight of the Fort Lauderdale Flight Standards District

Office (FSDO), Air Sunshine developed and received approval for its own inspection

28 Airmark Overhaul is an FAA-approved maintenance vendor for Air Sunshine.

29 Maintenance records were not available from the dates of manufacture of the right and left engines to

the dates of the overhauls.

30 For information about TCMís recommended overhaul limit and Air Sunshineís overhaul interval, see

section 1.6.1.3. 
Factual Information 11 Aircraft Accident Report

program. The companyís initial AAIP was a 3-phase, 60-hour inspection program.

A different phase was performed every 60 hours of operation along with a routine

servicing check, which included an engine oil change, a ground run-up, and a visual

inspection of the airframe. Phases 1 through 3 comprised one full cycle, and an airplane

had to complete one full cycle (that is, the entire aircraft had to have been inspected) every

180 hours of operation. 

On November 4, 2002, Air Sunshine submitted revision No. 10, which proposed to

change the companyís AAIP to a 6-phase, 60-hour inspection program, to the FAA for

approval. On January 9, 2003, the FAA approved the change,31 and the 6-phase, 60-hour

inspection program was in effect at the time of the accident. Each of the six phase

inspections focused on one major airplane section. Phase 1 covered the powerplants,

including a focused engine inspection and a differential compression check of the engine

cylinders; phase 2 covered the wings; phase 3 covered the cabin; phase 4 covered the

landing gear; phase 5 covered the fuselage; and phase 6 covered the empennage. Phases 1

through 6 comprised one full cycle, and an airplane had to complete one full cycle every

360 hours of operation. The last phase 1 inspection was performed at FLL from June 12

to 14, 2003. During this inspection, each engine was determined to have a time since

overhaul of 2,187 flight hours. 

1.6.1.2 Differential Compression Checks

TCM Service Bulletin (SB) 03-3 states that differential compression checks are

conducted to identify leaks in the engine cylinders and the sources of any leaks that were

found and that leaks can be caused by abnormal or excessive wear inside the engine

cylinders or their components, problems with the valves or valve seats, and cracks in the

cylinders. The SB also states that compression checks should be conducted ìat each

100 hour interval, annual inspection or when cylinder problems are suspected.î32

According to SB 03-3, before conducting the differential compression check, the

acceptable pressure leakage limit for the equipment being used and the atmospheric

conditions at the time that the check is conducted need to be established. SB 03-3 contains the

following instructions on how to perform differential compression checks on all of its engines: 

ï remove the most accessible spark plug from each of the six cylinders on each

engine;

ï turn the engine crankshaft by hand in the direction of rotation until the piston is

coming up on top dead center at the end of the compression stroke;

31 In early 1998, Air Sunshine requested that its operating certificate be transferred from the FAAís Fort

Lauderdale FSDO to its San Juan FSDO. The FAA granted the request, and the transfer took place on June 2,

1998. The companyís operating certificate was under the jurisdiction of the San Juan FSDO when the

company applied and was approved to change its AAIP. For more information about FAA oversight of Air

Sunshine, see section 1.17.2.

32 For information about the postaccident change to the differential compression check interval and

other changes to Air Sunshineís AAIP, see section 1.17.2.5.
Factual Information 12 Aircraft Accident Report

ï install a cylinder adapter in the spark plug hole and connect a differential

pressure tester to the cylinder adapter and slowly open the cylinder pressure

valve and pressurize the cylinder to 20 pounds per square inch (psi); 

ï continue to rotate the engine in the direction of rotation, against the pressure,

until the piston reaches top dead center (that is, with the piston at the end of the

compression stroke and the beginning of the power stroke);

ï open the cylinder pressure valve completely;

ï move the propeller slightly back and forth with a rocking motion while

directing regulated pressure of 80 psi into the cylinder and adjust regulator as

necessary to maintain a pressure gauge reading of 80 psi; and

ï record the pressure indication on the cylinder pressure gauge.

The difference between the pressure directed into the cylinder (80 psi) and the

cylinder pressure shown on the regulator pressure gauge is the amount of leakage through

the cylinder. Any cylinder pressure level greater than that established as the acceptable

pressure leakage limit indicates an acceptable operating condition for a reciprocating

engine. The SB recommends that, if the cylinder pressure levels are less than the

acceptable pressure leakage limit, cylinder borescope inspections should be conducted. 

1.6.1.2.1 June 12 to 14, 2003, Differential Compression Checks

As noted previously, the last differential compression checks performed on the

accident airplaneís engines occurred from June 12 to 14, 2003, as part of the airplaneís last

phase 1 inspection. According to the Director of Maintenance, he performed the checks on

the left engine while the assistant mechanic watched and then recorded the readings in the

inspection record. The cylinder differential compression check form33 in Air Sunshineís

Maintenance Manual contains the following: ìCAUTION - It is recommended that

someone hold the propeller during this check to prevent possible rotation.î (See figure 2.)

The Director of Maintenance stated that, after completing the checks on the left

engine, he asked the assistant mechanic if he felt capable of performing the checks on the

right engine without supervision. The director stated that the assistant replied that he could

perform the checks; as a result, the director left the assistant to perform the checks by

himself without supervision. According to the director, he asked the assistant mechanic to

record the compression check readings for the right engine on a sheet of paper so that he

could review them before making the entries in the cylinder differential compression check

form in the inspection records; however, the assistant mechanic recorded the readings

directly in the inspection record. Figure 2 also shows the compression check readings (in

psi) recorded in the inspection record by the assistant mechanic for both engines.

Accounting for the check equipment used at the time that the checks were performed, the

Safety Board determined that the acceptable pressure leakage limit was 54 psi. 

33 The cylinder differential compression check form is part of the companyís AAIP phase 1 inspection

package.
Factual Information 13 Aircraft Accident Report

Note: According to the assistant mechanic and the Director of Maintenance, the number recorded for right engine cylinder 

No. 3 was ì55.î (Safety Board investigators who reviewed the document noted that the number could be either ì55î or ì25.î) 

The assistant mechanicís signature and A&P certificate number have been redacted.

Figure 2. Cylinder differential compression check form.
Factual Information 14 Aircraft Accident Report

During postaccident interviews, the assistant mechanic stated that he had never

performed a differential compression check before conducting the checks on the accident

airplaneís right engine. The assistant stated that his normal duties included changing oil,

tires, cables, and spark plugs and cleaning the airplane. When a Safety Board investigator

asked the assistant how to perform the compression check, he stated only that the spark

plugs had to be removed from the cylinders and that the piston had to be at top dead center

on its compression stroke.

The Director of Maintenance stated that, as he was reviewing and signing off on

the dayís maintenance work, he noticed that two of the readings obtained from the

compression checks of the right engine (0 psi for the No. 2 cylinder and 20 psi for the

No. 4 cylinder)34 were ìhighly questionable.î The director stated that he asked the

assistant mechanic if he had been careful to get the piston at top dead center on its

compression stroke on each cylinder when he performed the check. The director indicated

that, although the assistant stated that he had been careful to get the piston into its required

position, he appeared uncertain when asked specifically about the two questionable

cylinder readings. The director told the assistant mechanic that the compression checks on

the right engine cylinders would have to be repeated. 

According to the Director of Maintenance, after he repeated the checks on the right

engine, all of the cylinderís compression readings were in the 70-psi range, including the

two cylinders with low readings from the first compression checks. The director stated

that, when he did the rechecks, he was careful to get the piston at top dead center on its

compression stroke and hold the propeller while adding the pressure. He added that, if the

compression level readings had remained low, he would have grounded the airplane. The

director stated that he had the assistant mechanic observe the checks and record the

readings on a sheet of paper. The assistant mechanic stated that he gave the sheet of paper

to the director but that he did not see what the director did with the paper. The director

stated that he recorded the corrected readings on a new cylinder differential compression

check form; however, company personnel did not locate the corrected form. The director

stated that he did not conduct cylinder borescope inspections on cylinder Nos. 2 and 4

because the repeated compression checks yielded readings that were within acceptable

limits.

The Director of Maintenance stated that the company had removed and replaced

an engine cylinder assembly about five or six times in the last 3 years. The director stated

that, before applying torque to the cylinder studs, maintenance personnel coated the studs

with an aluminum-copper-graphite, lithium-based antiseize compound manufactured by

Permatex. TCM SB 96-7B specifies that clean 50-weight aviation-grade engine oil should

be applied to the studs and through bolts before applying torque. Permatex does not

recommend using antiseize compound in high-vibratory environments because such use

could contribute to the loss of torque.

34 The Director of Maintenance stated that he would consider any reading below 58 psi to be too low

and that low readings would require that the cylinder be rechecked. The director did not mention that the

reading recorded for cylinder No. 3 was too low, even though he stated that it was ì55.î
Factual Information 15 Aircraft Accident Report

1.6.1.3 Time Between Overhauls 

TCM Service Information Letter 98-9A recommends that TSIO-520-VB engines

have a time between overhaul (TBO) of 1,600 hours. Air Sunshine began operating its

airplanes equipped with TSIO-520-VB engines in accordance with this recommendation.

After Air Sunshineís inspection program received FAA approval in early 1992,35 the

company applied to the Fort Lauderdale FSDO for a 200-hour extension of its TBO per

the procedures outlined in FAA Order 8300.10, Airworthiness Inspectorís Handbook.

36

The FAA principal maintenance inspector (PMI) for Air Sunshine granted its request and

allowed the company to increase its TBO by 200 hours. From late 1992 to late 1995, Air

Sunshine applied for four additional TBO extensions (of 200 hours, 200 hours, 100 hours,

and 100 hours) for a total TBO extension of 800 hours. The FAA granted approval for all

of the requested extensions, which resulted in a TBO of 2,400 hours. 

According to FAA Order 8300.10, approval of TBO extensions is granted based on

ìsatisfactory service experience and/or a teardown examination of at least one exhibit

engine.î Neither the FAA nor Air Sunshine had retained the paperwork that related to the

five requests for, and approvals of, the extensions of the companyís TBO for longer than

the 2 years required by the FAA. However, Air Sunshine provided the Safety Board with

four teardown reports prepared by Airmark Overhaul (which were submitted as support

for the first four TBO extension requests) and one report prepared by TCM (which was

submitted as support for the last request). These reports were dated July 16, 1992;

November 17, 1992; March 20, 1994; January 20, 1995; and October 9, 1995. All of the

teardowns conducted by Airmark and TCM were of TCM-rebuilt engines.

After Air Sunshine received approval for the last 100-hour TBO extension, the

company petitioned the Fort Lauderdale FSDO to change the companyís operations

specifications to reflect the 2,400-hour TBO, and the Fort Lauderdale FSDO granted the

request under the condition that the companyís airplane engines be rebuilt by TCM. In late

August/early September 1999, after Air Sunshine transferred its operations certificate to

the San Juan FSDO, the company petitioned the San Juan FSDO to remove from the

companyís operations specifications the requirement that TCM rebuilt engines must be

used. 

In a letter dated September 9, 1999, the FAA PMI for Air Sunshine stated that he

would grant the companyís request provided it (1) monitored the performance of newly

overhauled engines and reported any abnormal conditions to the San Juan FSDO,37 (2) used

35 Air Sunshine was required to have its own AAIP to receive FAA approval for TBO extensions.

36 FAA Order 8300.10 indicates that TBO extensions for reciprocating engines can be granted in

increments of up to 200 hours.

37 A review of Air Sunshine and FAA records revealed that the company made no reports to the FAA

between the date of this letter and the date of the accident in which the company reported any abnormal

conditions of its overhauled engines.
Factual Information 16 Aircraft Accident Report

the approved overhaul facilities listed in its Maintenance Manual vendor list,38 and

(3) established standards for parts to be used during the overhaul process. The PMI added

that, if the engines did not perform satisfactorily, the companyís operations specifications

would be amended back to the original TBO of 1,600 flight hours.39

1.7 Meteorological Information

The closest airport to the location of the airplane wreckage was Grand Bahamas

International Airport (MYGF), Freeport, Bahamas, which was about 63.9 nautical miles

from where the airplane was located. MYGF does not have an automated weather system.

Weather observations are made by an on-site weather observer and are recorded in

coordinated universal time. Eastern daylight time is 4 hours behind coordinated universal

time.

The 1900 meteorological aerodrome report (METAR) (1500 local time, which was

about 30 minutes before the ditching) indicated that winds were 160° at 8 knots, visibility

was 10 nautical miles, clouds were broken at 2,000 feet, the temperature was 88.5° F, the

dew point was 74.1° F, and the altimeter setting was 30.09 inches of Hg. 

The 2000 METAR (1600 local time, which was about 30 minutes after the

ditching) indicated that winds were 140° at 10 knots, visibility was 10 nautical miles, a

few clouds were at 1,500 feet and were scattered at 2,000 feet, the temperature was 88.5° F,

the dew point was 74.1° F, and the altimeter setting was 30.08 inches of Hg.

1.8 Aids to Navigation

The distance measuring equipment on the MYAT VOR40 had been inoperative for

several years.

1.9 Communications

No communication problems were reported.

1.10 Airport Information

MYAT was the destination airport for flight 527. The airplane was ditched about

7.35 nautical miles west-northwest of the airport.

38 After its operations specifications were amended, Air Sunshine started using Airmark Overhaul, a

company on the FAA-approved vendor list, to overhaul its engines.

39 For information about postaccident changes to Air Sunshineís operations specifications, see

section 1.17.2.5.

40 VOR stands for very high frequency omnidirectional range.
Factual Information 17 Aircraft Accident Report

1.11 Flight Recorders

The accident airplane was not equipped with either a CVR or an FDR and was not

required to be so equipped.

1.12 Wreckage and Impact Information

1.12.1 General

The airplane was submerged in water for about 3 weeks after the accident.

Underwater photographs taken before the airplane was recovered from the water showed

that the window escape hatch adjacent to the pilot seat (1A) was open. The emergency

escape hatch adjacent to seats 2B and 3B was found closed. The top and bottom portions

of the main cabin door adjacent to seats 4A and 5A were found open.

Impact damage was noted on the lower fuselage skin from the wing main spar

forward, and damage was noted on the nose cone. The landing gear was found retracted. 

All of the airplaneís major components,41 except for the left aileron and the

outboard section of the right elevator and balance weight, were recovered attached to the

airplane. The separated sections were not recovered. The rudder trim tab actuator was

found positioned between 5° and 10° trailing edge tab right; the elevator trim tab actuator

was found positioned at 15° trailing edge tab down. The left flap was found extended

about 15°, and the cowl flap was nearly closed. The right flap was found extended about 15°,

and the cowl flap was open. An oil sheen was noted on the exterior surface of the right

engine upper cowling, from the louvers aft to the trailing edge of the wing; on the interior

surface of the upper cowling; and on the upper and lower exterior surfaces of the

horizontal stabilizer.

The left fuel selector valve handle in the cockpit was found positioned to the left

main fuel tank; the right fuel selector valve handle was missing; therefore, its position

could not be determined. The emergency crossfeed/shutoff valve handle was found

positioned to the crossfeed position. The left and right auxiliary fuel pump switches were

found in the off position. The left and right cowl flap controls were found out (closed) and

in (open), respectively. Both the flap selector and flap position indicator were found at

about 15° flaps extended,42 and the landing gear selector handle was found in the retracted

position. The elevator trim indicator was found positioned to full nose up. The aileron trim

indicator was found positioned slight left wing down. The rudder trim indicator was found

positioned nose left.

41 A major component is necessary for an airplane to sustain flight.

42 During postaccident interviews, the pilot stated that he did not extend the flaps during the flight. The

pilot stated that he would normally extend the flaps when he was about 3 miles from an airport. When he

was asked how the flaps became extended to 15°, the pilot replied that after the ditching, some of the

passengers crawled over him and that one of them might have hit the switch that extended the flaps. He

stated that the flaps were extended electrically and that he had left the power on after the ditching.
Factual Information 18 Aircraft Accident Report

All seats were found attached to the floor and were undamaged. All lapbelts were

present and were found to operate normally. The seatback stowage pockets for seats 2A

and 2B did not contain safety briefing cards;43 all of the other stowage pockets contained

briefing cards. 

Six packaged PFDs were found in the airplane. One PFD was found forward of the

pilot seat, and one PFD was found forward of the copilot seat. The remaining four PFDs

were found in their stowage areas (under seats 2A, 2B, 3A, and 5A). The PFDs were

brought to the Safety Boardís headquarters in Washington, D.C., and were examined on

August 28, 2003. The sealed plastic pouches were opened, and the PFDs were inflated by

pulling the inflation rings. All of the PFDs were undamaged and were found to operate

normally. Inspection records found inside the plastic pouches containing the PFDs

indicated that they had been inspected within the past 5 years, in accordance with Federal

regulations.

1.12.2 Engines and Propellers

The left engine was attached to the airframe, and the propeller was attached to the

engine. The outboard lower engine cowling had separated and was not located. The left

engine was removed and examined, under Safety Board supervision, at TCMís facility. All

six cylinders and their valves were intact. No evidence of preexisting damage was found.

The left propeller was removed and examined, under Safety Board supervision, at

McCauley Propellersí facility. The left propeller hub was intact and undamaged, and all

three blades were installed in the hub. Examination of the left propeller revealed no

evidence of preimpact damage. The feather-stop mechanism was attached and

undamaged, and the start-lock mechanism44 was intact and undamaged. 

The right engine was attached to the airframe in its normal position, and the

propeller was attached to the engine. Damage was noted on the leading edge skin from the

engine outboard to the wing tip; the leading edge skin from the engine nacelle inboard of

the wing root was crushed up and aft. The lower inboard engine cowling was separated

and was not recovered; the lower outboard engine cowling was in place. 

The right engine No. 2 (inboard aft) cylinder was found separated from the engine

crankcase, exposing a portion of the crankshaft, and held onto the engine by the exhaust

pipe tubing and by an electrical cable that was secured to the cylinder assembly by an adel

clamp. The two magnetos were found protruding through the upper outboard engine

cowling but remained attached to the engine by ignition leads. (See figure 3.) Two 6-point

flanged nuts, one 12-point flanged nut with a fractured threaded piece, and a nonfractured

connecting rod were recovered from the engine compartment area. Piston ring pieces were

found in the partially separated No. 2 cylinder assembly. 

43 The stowage pockets on these seatbacks held the briefing cards for use by the passengers in seats 3A

and 3B. For more information about the airplaneís interior configuration, see section 1.6.

44 As noted previously, the start-lock mechanism is a system designed to prevent the propeller from

traveling all the way to feather during normal engine shutdowns.
Factual Information 19 Aircraft Accident Report

The right engine was removed and examined, under Safety Board supervision, at

TCMís facility. After engine disassembly at TCM, some of the right engine components

were brought to the Safety Boardís Materials Laboratory in Washington, D.C., for further

examination. For additional information about the metallurgical inspections of the right

engine components, see section 1.16.3.

The right propeller was removed and examined, under Safety Board supervision,

at McCauley Propellerís facility. The right propeller hub was intact and undamaged, and

all three blades were intact and installed in the hub and appeared to be in the feathered

position. The blade angles were measured as follows: blade No. 1 was 82.2°, blade No. 2

was 82.4°, and blade No. 3 was 82.3°. The feather angle for this propeller is 82.2°

(+/-0.3°). All of the blade counterweights were present and in place. The propeller piston

was undamaged, and the centrifugal weights and springs were in place. The piston rod and

feathering spring were intact, in place, and undamaged. The feather-stop and start-lock

mechanisms were intact and undamaged. 

Figure 3. Exterior of the upper outboard engine cowling. 
Factual Information 20 Aircraft Accident Report

1.13 Medical and Pathological Information

Fluid specimens obtained from the pilot were sent to the Royal Bahamas Police

Forceís Forensic Science Laboratory for toxicological analysis. The fluid specimens tested

negative for alcohol and drugs.45

According to the Rand Memorial Hospital (Freeport, Grand Bahamas) autopsy

report, the cause of death for the deceased 4-year-old child was ìdrowning secondary to

plane crash.î According to the Princess Margaret Hospital (Freeport, Grand Bahamas)

pathology report, the deceased adult passenger had injuries ìconsistent with the history of

plane crash accident.î Further, the report stated that the deceased adult passenger had a

cerebral contusion and rib fractures. The report also stated that a ìsection of both lungs

showed edema and congestion.î 

1.14 Fire

No evidence of an in-flight fire was found, and the accident did not result in a

postcrash fire.

1.15 Survival Aspects

1.15.1 General

The pilot reported that he was not wearing his shoulder harness when the airplane

contacted the water and that he hit his head on the instrument panel during the ditching.46

During postaccident interviews, one passenger stated that the pilot ìdid not appear to have

much clarity and was not particularly coherentî after the ditching. Another passenger

stated that he ìtook charge of the situation because the pilot was incoherent in the water.î

The passenger also stated that the pilot ìdid not look like he could swimî and that he had

to give the pilot his PFD. 

The passenger in the copilot seat reported a bump on his head and a cut on his leg.

The passenger stated that he was not wearing his shoulder harness during the ditching

because the pilot had not informed him before the flight departed that his seat was so

equipped. The passengers in seats 2A and 2B reported bruises on their hips from the

lapbelts. The passenger in seat 3B reported a contusion on her forehead. 

After the airplane contacted the water, the pilot opened the pilot-side window

hatch. The pilot, four adult passengers (from the copilot seat and seats 2A, 2B, and 3B),

45 The drugs tested in the postaccident analysis included benzoylecgonine, barbiturates,

benzodiazapines, and opiates.

46 Title 14 CFR 91.105(b) requires that required flight crewmembers of a U.S.-registered civil aircraft

keep their shoulder harnesses fastened while at their assigned duty stations during takeoff and landing.
Factual Information 21 Aircraft Accident Report

and one child (who had been sitting on the passenger in seat 3Bís lap) evacuated the

airplane through the pilot-side window escape hatch. One adult and three children (from

seats 4A, 4B, 5A, and 5B) evacuated the airplane through the main cabin door. 

1.15.2 Emergency Briefings

Air Sunshineís FAA-approved General Operations Manual, Section 4, ìEmergency

Procedures,î contains the following guidance to pilots on briefing passengers before a

ditching:

ï review the emergency ditching evacuation procedures with the passengers;

ï instruct passengers to don life vests at that time, without inflating them in the

airplane; 

ï review the operation of the inflation ring and the manual/oral blow-up tubes;

and 

ï instruct passengers to inflate their life vests once they are outside of the aircraft.

As noted previously, passengers reported that the pilot did not tell them to retrieve

and don their PFDs before the airplane contacted the water. They stated that the only time

he addressed the passengers after the right engine failed and before the airplane contacted

the water was to tell them to ìcalm down.î

As the result of a postaccident focused inspection of Air Sunshine (conducted from

July 22 to August 29, 2003), the FAA instructed the company to amend its emergency

ditching procedures.47 The amended procedures contain the following guidance to pilots

on briefing passengers before a ditching:

ï instruct all passengers to don life vests as soon as any emergency occurs during

overwater operation;

ï instruct passengers to familiarize themselves with emergency evacuation

procedures, including special evacuation procedures for those passengers who

are assisting others, such as children and handicapped individuals;

ï review ditching procedures before ditching, including instructing passengers to

partially inflate their life vests through the use of the blow-up tubes; and

ï instruct passengers that, only once they have gotten outside the airplane, they

should fully inflate their life vests by pulling the inflation ring.

1.15.3 Personal Flotation Devices

Title 14 CFR Part 135 requires specific emergency equipment, including approved

life preservers and rafts, a survival kit, and an emergency locator transmitter, to be

47 For more information about the FAAís postaccident focused inspection of Air Sunshine, see

section 1.17.2.4.
Factual Information 22 Aircraft Accident Report

installed on airplanes that conduct extended overwater operations (that is, operate flights

over water at a horizontal distance greater than 50 nautical miles from the nearest

shoreline). Because Air Sunshine flight 527 did not qualify as an extended overwater

flight, the airplane was not required to be equipped with such emergency equipment.

However, 14 CFR 91.205 requires that aircraft operated for hire over water and beyond

power-off gliding distance to shore be equipped with approved flotation gear that is

readily available to each occupant.48

The airplane was equipped with 10 PFDs.49 According to the markings on the

PFDs, they met the requirements of FAA Technical Standard Order (TSO) C-13e, which

defines minimum performance standards for PFDs. The markings on the PFDs indicated

that they were approved for use by adults and children and that children should have their

PFDs put on them by adults per crew instruction.

The PFDs on the airplane were vests with two separate symmetrically arranged

chambers and a retention strap. The PFD is donned when a user inserts its head through a

hole in the PFD and fastens the retention strap around its waist. A PFD is inflated when

the user pulls an inflation ring that discharges carbon dioxide cartridges into the two

chambers. The user can also inflate a PFD by blowing into a tube that is located on each

chamber. A correctly donned and inflated PFD that meets the requirements of TSO C-13e

should provide the user with 35 pounds of buoyancy, automatically correctly position the

user in the water within 5 seconds, and hold the userís nose and mouth ìclear of the

waterline.î

Only 4 of the 10 PFDs installed on the airplane were retrieved and used by the

passengers.50 The passenger in seat 3B, who was holding a child on her lap, retrieved the

PFD from under her seat. The passenger in seat 5A retrieved three PFDs and put them on

the three children accompanying her before the airplane contacted the water. 

According to the passenger in the copilot seat, he could not retrieve his PFD

because it was wedged between the seat and the wall of the airplane. The passenger in

seat 2A and another passenger who tried to help her stated that they could not retrieve the

PFD for seat 2A ìbecause the Velcro that closed the container [the fabric pouch] would

not separate.î These two passengers stated that they exited the airplane without the PFD

when the water reached knee level. The passengers who were not able to retrieve their

PFDs did not try to retrieve them until the airplane contacted the water.

Once the airplane occupants were in the water, airplanes circling the area at the

time of the accident dropped several PFDs. The passengers retrieved some of these PFDs

and distributed them. The adult female passenger (in seat 5A) and the child accompanying

48 This requirement applied to flight 527.

49 According to the President of Air Sunshine, after Tropical International Airlines purchased the

airplane in 1997, that company installed the PFDs on the airplane, which were stowed in fabric pouches that

the company had made.

50 As noted in section 1.12.1, the six PFDs that were still in the airplane were found undamaged and

were capable of normal operation. 
Factual Information 23 Aircraft Accident Report

her who died after the evacuation were not wearing a PFD when they were recovered from

the water. The passenger in seat 1B reported that he took the PFD off of the child who died

after the evacuation. This passenger stated that, when he took the PFD from the child, it

was not inflated and that one of the inflation chambers had a hole in it. The passenger

stated that he provided the PFD to another passenger and that the undamaged chamber

inflated normally.51 Another passenger stated that the other two childrenís PFDs were also

not inflated and that he inflated one chamber on each of their vests.

No information indicates whether the other passengers donned their PFDs

correctly. However, during postaccident interviews, none of the passengers appeared to be

familiar with the proper donning and inflating procedures (for example, none of the

passengers reported fastening the retention straps around their waists). 

Passengers reported that the airplane sank within several minutes after contacting

the water. Passengers stated that they tried to stay together in the water; however, two

groups were eventually formed, and, because of the waves, the two groups drifted apart.

Passengers reported that two of the children traveling with the female passenger in seat 5A

were extremely frightened when they entered the water and that they were frantic to the

point that they were ìdangerousî to nearby passengers who were treading water.

Passengers also reported that the female passenger in seat 5A who was not wearing a PFD

was seen floating face down shortly after entering the water. The passengers were in the

water for about 1 1/2 hours before being rescued, as detailed in section 1.15.4. 

1.15.4 Search and Rescue

At 1533, the Air Sunshine pilot who had just taken off from Marsh Harbor

transmitted a distress call. (That airplaneís altitude was too low to allow the pilot to

contact the Miami ARTCC directly.) The pilot of Gulf flight 9267 heard the distress call

and relayed the message to the Miami ARTCC. At 1540, the Miami ARTCC notified

MYGF that Air Sunshine flight 527 was in the water. MYGF personnel responded that the

airport did not have any helicopters and that, therefore, it could not assist with the search

and rescue. At 1541, the Miami ARTCC notified the U.S. Coast Guard at Opa-Locka,

Florida, that the flight 527 airplane was in the water.

After receiving the notification, the U.S. Coast Guard launched from Air Station

Miami one HH-65 (an Aerospaciale Dolphin helicopter), which departed about 1551 and

arrived on scene about 1702, and one Falcon jet, which departed about 1606 and arrived

on scene about 1636. In addition, the Coast Guard launched one HH-60J (a Sikorsky Jayhawk

helicopter) from Andros Island, Bahamas, which departed about 1605 and arrived on scene

about 1702.52 Two life rafts were dropped from the Falcon after it arrived on scene. One of

51 The deceased childís PFD was not recovered; therefore, the condition of her PFD could not be

determined.

52 According to the Coast Guard, about 1605, the winds at the crash site were about 11 knots, and the

waves were about 4 feet high. The Coast Guard did not estimate wave height for the time of its arrival on scene.
Factual Information 24 Aircraft Accident Report

the rafts landed near one of the groups of passengers53 and was used by two adult

passengers; the other raft did not land near any of the passengers. 

A rescue diver from the HH-65 recovered the pilot, one child passenger, and two

adult passengers, all of whom were hoisted into the helicopter and then flown to MYGF.

According to the rescue diver from HH-60J, he found two children wearing PFDs, and

each of the children was holding an arm of an adult female who was floating face down in

the water and ìappeared to be deceased.î The diver recovered the two children, removed

one of the childrenís PFDs, and placed the PFD on the deceased female.54 The rescue diver

then recovered two additional adult passengers who were hanging onto one of the life rafts

dropped from the Falcon. All of these passengers and the rescue divers from both

helicopters were hoisted into HH-60J.

At the request of a Royal Bahamian police officer, a private fishing boat went to the

accident site about the same time as the helicopters arrived. Two men on the boat retrieved

the bodies of two passengers. The flight crew of HH-60J stated that they saw occupants on

the boat performing CPR on the two passengers. HH-60J dropped a rescue diver who

determined that one of the passengers was a child. The rescue diver hoisted the child onto

the helicopter and performed CPR on the child until landing at MYGF. The boat carried the

deceased female passenger to MYGF. After arriving at the MYGF, all of the passengers that

had been hoisted into HH-60J were transported to Rand Memorial Hospital.

1.16 Tests and Research

1.16.1 Cessna Airplane Performance Data

The Cessna 402C Aircraft Information Manual, Section 5, ìPerformance,î

contains a performance chart for estimating the airplaneís climb rate with one inoperative

engine. Conditions for the use of the chart include the following: operative engine power

at maximum (2,700 rpm and 39 inches Hg manifold pressure), fuel flow in the white arc

on the fuel flow gauge,55 landing gear retracted, flaps at 0°, inoperative propeller

feathered, wing bank 5° toward operative engine with about 1/2-ball56 slip indicated on the

turn-and-bank indicator, and inoperative engine cowl flaps closed. Safety Board

investigators used the information from Cessnaís performance chart and accounted for the

53 According to the commander of HH-60J, when the helicopter arrived on scene, the passengers were

clustered in three groups, about 110 yards away from each other.

54 The rescue diver stated that he placed one of the childrenís PFDs on the deceased female so that she

would be easier to locate after the survivors were retrieved from the water.

55 According to Cessnaís Aircraft Information Manual, white arc is used for ì(Takeoff and Engine

Inoperative Power-Sea Level to 12,000 feet) 200.0 Pounds per hour (16.8 psi) to 210.0 Pounds per hour

(18.0 psi).î

56 During coordinated, straight-and-level flight, the ball is centered between the turn-and-bank

indicatorís reference lines. In the event of an engine failure, the pilot banks 5° toward the operative engine to

ensure that about a 1/2-ball slip is indicated on the turn-and-bank indicator to create the most efficient bank

angle, which creates minimum drag. 
Factual Information 25 Aircraft Accident Report

weight of the airplane (between 6,444 and 6,534 pounds),57 the outside air temperature

(90° F), the winds (about 15 knots),58 and the altitude (3,500 feet) at the time that the right

engine failed in estimating that the airplane would have had a climb rate of about 200 fpm

if nothing had occurred to negatively affect the airplaneís performance. 

Cessna provided the following climb rate penalty data:59 flaps at 15° (the

configuration at which the accident airplane was found) at 103, 100, and 95 knots yields

penalties of -165, -155, and -145 fpm, respectively; a windmilling propeller (pilot and

passenger statements indicated that the right engine propeller was windmilling, not

feathered, after the right engine failed) yields a penalty of -400 fpm; cowl flap of

inoperative engine open (the postaccident configuration in which the airplaneís right

engine cowl flap was found) yields a penalty of -9 fpm; and protruding magnetos (the

right engine magnetos penetrated the engine cowling in flight) yields a penalty of -4 fpm. 

1.16.2 Airplane Performance Study

The Safety Board conducted an airplane performance study to establish the effects

that the pilotís actions, airplane damage, and windmilling propeller had on the airplaneís

performance after the right engine failed. Because the airplane did not have an FDR or a

CVR and no radar data relating to the accident flight were available, the study used

statements from the pilot, passengers, and Air Sunshineís station manager to determine the

sequence of the pilotís actions throughout the flight. 

With the use of the data provided by Cessna and a range of average indicated

airspeeds between 115 and 95 knots,60 the airplane performance study determined that the

airplaneís descent rate was between about 560 and 212 fpm during its descent from

3,500 to 2,000 feet. The airplane traveled between about 5 and 10 nautical miles during

this portion of the flight. With the use of a range of average indicated airspeeds between

105 and 90 knots, the study determined that the airplaneís descent rate was between about

429 and 360 fpm during its descent from 2,000 feet to the point of contact with the water.

The airplane traveled about 7.6 nautical miles during this portion of the flight. At the time

of the right engine failure, the airplane was about 20 to 25 miles from MYAT. The study

determined that the airplane was airborne for at least 7 minutes after the right engine failed

and before it contacted the water. At 90 knots, and with the engine damage, the airplane

57 The difference in weight would have caused less that a 40 fpm difference in the climb rate.

58 Airport weather data were obtained from Miami International Airport and MYGF. The data showed

that the estimates provided by the pilot (the winds were about 15 knots, and the outside air temperature was

80° to 90° F) at the time of the ditching were accurate.

59 Cessna could not quantify the penalties for the following variables that also could have decreased the

climb rate: operation of the airplane at greater or less than the recommended wing bank of 5° toward

operative engine; operation of the airplane at greater or less than the recommended 1/2-ball slip on the

turn-and-bank indicator; and operation of the airplane on a nonsteady descent (for example, decreasing pitch

angle to increase speed and then reducing pitch to arrest descent rate).

60 According to the pilot, the blue radial on the accident airplaneís airspeed indicator, which shows the

single-engine best climb rate, was pointing to about 105 knots.
Factual Information 26 Aircraft Accident Report

could have tolerated a descent rate of an average of about 200 fpm and been able to

maintain flight and reach MYAT.

1.16.3 Metallurgical Inspections

1.16.3.1 Right Engine Cylinder Assemblies

The right engine No. 2 cylinder assembly was separated from the engine

crankcase. The other five cylinder assemblies were intact and attached to the engine

crankcase. 

The Nos. 1, 3, 4, 5, and 6 cylinder bores were covered with corrosive material and

sand and salt residue, consistent with salt water immersion. No discernible damage to the

cylinder assemblies or to the valves was noted. All of the valves and valve springs were

intact and undamaged. The valve faces and springs were coated with sand, salt, and oil,

and the faces were oxidized.

The No. 2 cylinder assembly was generally intact with no apparent damage to the

valves or cylinder head. The cylinder bore was covered by a layer of corrosive material;

no large-scale marking, scoring, or gouging was found under the corrosion. 

The No. 2 cylinder skirt area (the inboard portion of the cylinder that projects into

the engine crankcase when assembled) was damaged and deformed in multiple places.

The damage displaced various portions of the inboard edge of the cylinder skirt both

toward and away from the cylinder centerline. The spacing between the deformed areas

was about equal to the distance between the No. 2 cylinder hold-down studs and through

bolts. The cylinder base flange was also damaged with the two upper aft mounting holes

(at the intact stud locations) distorted adjacent to the inboard (case side) surface. 

Five of the engine cylinder assemblies (Nos. 1 through 5) had markings on the

heads and base flanges, identifying them as FAA Parts Manufacturing Approval

components. The letters ìECî were steel-stamped into the cylinder head, indicating that

the cylinders were manufactured by Engine Components, Inc (ECI). One of the valve

rocker bosses on each of these cylinders was also marked with steel-stamped numbers 29689-1

through -5. The first five numbers corresponded to the work order number for the last

engine overhaul performed by Airmark Overhaul, and the last number corresponded to the

position of the cylinder (1 through 5). The cylinders were installed in their respective

positions on the engine crankcase. 

The markings on the No. 6 cylinder were not consistent with those on an

ECI-manufactured cylinder. The letters ìDETî and ìEî and the number ì99î were

steel-stamped into the cylinder head. One of the valve rocker bosses was marked with the

steel-stamped number ì33258-3,î61 and another of the rocker bosses was vibro-etched

with the number ì7-99.î 

61 This work order number corresponded to a propeller strike inspection that was conducted on another

one of the companyís engines, serial number 816113-R. For more information about this engine, see section

1.17.1.3.1. 
Factual Information 27 Aircraft Accident Report

1.16.3.2 Right Engine Pistons

The Nos. 1, 3, 4, 5, and 6 pistons from the right engine were intact. The No. 2

piston was found fractured into two large pieces and many small pieces. Only about

35 percent of the No. 2 piston was recovered. 

Magnified optical examinations of the fractures on the No. 2 piston found features

consistent with overstress separations; no indications of preexisting cracking were found.

On the largest piece, the piston was circumferentially fractured along the lower oil control

ring and vertically in the plane of the piston pin but offset to one side. Deformation on the

outer edge of the piston skirt adjacent to the fracture at the oil control ring groove was

consistent with partial canting of the piston in the cylinder after the fracture occurred.

1.16.3.3 Right Engine Crankcase

The left half of the right engine crankcase was fractured and damaged in line with

the No. 2 cylinder connecting rod, which was consistent with continued rotation of the

engine and flailing of the connecting rod after the complete separation of the cylinder. The

right half of the engine crankcase was also damaged in line with the No. 2 cylinder

connecting rod. The main portion of the connecting rod was heavily distorted in the rod

bearing and piston pin areas. The piston pin area had many impact marks, and the pin hole

and bushing were flattened. The connecting rod bolt pieces were also distorted and

fractured through the shank. Optical examinations revealed fracture features consistent

with overstress separations. A portion of the crankcase, which contained the two upper

center studs of the No. 2 cylinder, was missing. 

The engine crankcase surfaces that contact the cylinder skirt and base flange of the

No. 2 cylinder contained several different impact marks and contact features. Small, raised

ridges were present on the forward side of the mounting face corresponding to the

installed edges of the No. 2 cylinder base flange. Additionally, the bore portion of the

crankcase that mates with the No. 2 cylinder skirt contained several sharp circumferential

dents, scrapes, and other contact marks that are consistent with progressive outboard

movement of the cylinder skirt. The cylinder skirt edge marks continued onto the lower

portion of the mounting surface where a series of concentric dents, which matched the

machined contour and overall radius of the innermost edge of the cylinder skirt, were

found. Light fretting damage was noted in some areas of the contact surface with the

cylinder base flange.

1.16.3.4 Right Engine No. 2 Cylinder Hold-Down Studs and Through Bolts

Of the eight hold-down studs and two through bolts that retain the No. 2 cylinder to

the engine crankcase, three of the studs were found intact in the crankcase without nuts, four

of the studs and the two through bolts were found fractured, and one of the studs was not

found. The intact studs found in the crankcase without nuts had minimal thread damage.

The outboard portions of one of the fractured hold-down studs and one of the

fractured through bolts were recovered. The stud piece was found without a nut attached,
Factual Information 28 Aircraft Accident Report

and the through bolt piece was found with a nut attached. The outboard portions of the

other three fractured studs were not recovered. The other fractured through bolt, which is

where the nut would normally be, was not recovered. Figure 4 shows the condition in

which the right engine No. 2 cylinder retention system components were found.

Note: The cylinder base flange is outlined in blue, and the mounting surface is outlined in red.

Optical and scanning electron microscopic examinations of four of the hold-down

stud and two of the through bolt fractures found features that were consistent with

high-stress and low-cycle fatigue propagation. For all of the studs and through bolts with

fatigue cracking, initiation was from multiple locations in a thread root along one side of the

fastener. The fatigue propagated in a high-stress manner with parallel fissures and striations

until ductile overstress occurred at about 50 percent of the fastenerís cross-section. Some

spots of corrosive material were visible at random areas across the fractures; however, little

or no oxidation or corrosion was apparent in the fracture origin areas. A comparison of

height measurements of the No. 2 cylinder studsí features with features on other cylinder

studs in the engine crankcase revealed that the studs had been installed to similar depths.

Figure 4. The condition in which the right engine No. 2 cylinder retention system 

components were found. 

Through Bolt Fatigue,

Nut in Place

Stud Intact,

Case Threads Stripped,

No Nut

Through Bolt Fatigue,

Outboard Piece

Not Recovered

Stud Fatigue,

Outboard Piece 

Not Recovered

Stud Fatigue,

Outboard Piece 

Not Recovered

Stud Fatigue,

Outboard Piece 

Not Recovered

Stud Intact,

No Nut

Stud Intact,

Bent, No Nut

Stud Intact,

Missing from Case

Stud Fatigue,

Outboard Piece 

Recovered, No Nut
Factual Information 29 Aircraft Accident Report

1.16.3.5 Cylinder Hold-Down Nuts

The cylinder hold-down nuts from the Nos. 1, 3, 4, 5, and 6 right engine cylinders

were recovered on their respective hold-down studs and through bolts; three of the

hold-down nuts were found in the engine compartment. Thirty 7/16-inch-diameter,

6-point, flanged cylinder hold-down nuts were examined. Two of these hold-down nuts

were found in the engine compartment after recovery of the airplane, and 28 of these

hold-down nuts were removed from the right engine cylinders during engine teardown.

 Initial optical examinations found two different styles of nuts. Seven of the nuts

had concave transition from the wrench flats to the enlarged washer flange. These nuts

were consistent with an exemplar cylinder hold-down nut provided by Superior Air Parts

with standard 7/16-20 UNF-3B thread form.62 Twenty-three of the nuts had a convex

transition from the wrench flats to the enlarged washer flange and were embossed with

two opposed sets of parallel lines. These nuts were consistent with TCM flanged nuts with

the optional, nonstandard Spiralock thread form.63 According to TCM, the company has

exclusively procured cylinder hold-down nuts with the Spiralock thread form since

about 1990. One of the nuts found loose in the engine compartment was a Superior-style

hold-down nut, and the other nut was a TCM-style nut with the Spiralock thread form.

According to Airmark Overhaulís Quality Assurance Manager, the company uses

OEM-specified hold-down nuts or nuts provided by Superior Air Parts. The manager

stated that, since he began working at Airmark in April 1984, if the company was

overhauling an engine and 36 6-point cylinder hold-down nuts were needed and 24 with a

TCM part number and 12 with a Superior Air part number were in stock, both types of

nuts would be used to complete the overhaul rather than hold up production. He stated that

this procedure was ìaccepted in industry.î

1.17 Organizational and Management Information

1.17.1 Air Sunshine

Air Sunshine, Inc., was formed in June 1982 and began conducting Part 135

on-demand charter flights on September 2, 1982, and Part 135 scheduled commuter flights

in 1983. The company provides commuter and charter services in South Florida and the

Caribbean. The company has offices and a permanent maintenance facility in Fort

Lauderdale. The company has a ticket counter and two rooms at Luis Munoz Marin

International Airport (SJU), San Juan, Puerto Rico, but no permanent maintenance facility

there. Air Sunshineís President stated that the company keeps its maintenance records in

the two rooms it has at SJU. 

62 Standard 7/16-20 internal threads have a 7/16-inch major diameter and 20 threads per running inch of

UN fine 60° threads with a class 3 fit.

63 Spiralock internal threads are proprietary and were developed by Spiralock Corporation, a subsidiary

of Detroit Tool Industries Company. The internal threads of the Spiralock nut engage the external threads at

the crests of the stud threads.
Factual Information 30 Aircraft Accident Report

At the time of the accident, the company employed 12 pilots, 10 of whom were

captains and 2 of whom were first officers. According to Air Sunshineís President, the

company typically employed three A&P-certified mechanics and one or two assistant

mechanics in San Juan and four A&P-certified mechanics and three assistant mechanics in

Fort Lauderdale. The company operated three to four flights daily out of FLL and about

six to eight flights daily out of SJU with a fleet of seven Cessna 402C airplanes and one

Embraer 110 airplane. 

The Director of Maintenance stated that company maintenance was conducted in

both Fort Lauderdale and San Juan. According to the director, if an airplane is in Fort

Lauderdale when an inspection becomes due, the inspection is conducted there. He stated

that, because most of the flights conducted on its Cessna 402 airplanes originated in San

Juan, most of the inspections of these airplanes were conducted there.64 Air Sunshineís

President stated that extensive maintenance and sheet metal work were conducted in Fort

Lauderdale because the company owned a hangar at FLL. He stated that inspections

conducted in San Juan were typically conducted on the ramp and that, if an airplane

needed to be ìplaced on jacks,î the company would obtain hangar space at SJU.

Since March 26, 1987, Air Sunshine has experienced four incidents and six

accidents, including the flight 527 accident. Three of the accidents, including the accident

flight, resulted in fatalities. On January 23, 1992, a Cessna 402C crashed near Clewiston,

Florida, and two people were killed. On February 8, 1987, a Cessna 402C crashed into the

Atlantic Ocean while on final approach to Cyril E. King Airport, Charlotte Amalie, Virgin

Islands, and two people were killed. Both accidents were determined to be caused by pilot

error; no mechanical malfunctions were reported with either airplane. 

1.17.1.1 Air Sunshineís In-Flight Engine Failure Procedures

In-flight engine failure procedures were taught during company training and were

contained in Air Sunshineís Training Manual. The manual states that, if an engine were to

fail in flight, the pilot should comply with memory items and follow the prescribed checklist.

Air Sunshineís Training Manual, section 3, revision 6, dated May 10, 1990, contains the

following in-flight engine failure procedures:

1. Inoperative Engine ñ DETERMINE.

2. Operative Engine ñ ADJUST as required.

Before Securing [shutting down] Inoperative Engine:

3. Fuel Flow ñ CHECK. If deficient, position auxiliary fuel pump to ON.

4. Fuel Selectors ñ MAIN TANKS (Feel For Detent).

5. Fuel Quantity ñ CHECK.

64 Air Sunshineís General Manager reported to Safety Board investigators that the company conducted

45 inspections of its Cessna 402 airplanes in Fort Lauderdale and 17 inspections of its Cessna 402 airplanes

in San Juan between January 1 and July 13, 2003.
Factual Information 31 Aircraft Accident Report

6. Oil Pressure and Oil Temperature ñ CHECK.

7. Magneto Switches ñ CHECK ON.

8. Mixture ñ ADJUST. Lean until manifold pressure begins to increase, then

enrich as power increases.

Air Sunshineís Training Manual states that, if the engine does not start after

performing the first eight steps of the in-flight engine failure procedures, the pilot was to

perform the following procedures:65

9. Inoperative Engine ñ SECURE [shut down].

a. Throttle ñ CLOSE.

b. Mixture ñ IDLE CUT-OFF.

c. Propeller ñ FEATHER.

d. Fuel Selector ñ OFF (Feel For Detent).

e. Auxiliary Fuel Pump ñ OFF.

f. Magneto Switches ñ OFFÖ

i. Cowl Flap ñ CLOSEÖ

10. Trim Tabs ñ ADJUST 5° bank toward operative engine with approximately

1/2 ball slip indicated on the turn and bank indicator.

Air Sunshineís Training Manual also stated that, if an engine failure were to occur,

the single-engine best climb rate should be maintained regardless of whether the altitude

could be maintained because that speed guaranteed the best climb rate or the least altitude

loss with an inoperative engine. Cessnaís 402C Aircraft Information Manual, Section 3,

ìEmergency Procedures,î states the following:

The one engine inoperative best rate-of-climb speed becomes important when

there are no obstacles ahead on takeoff, or when it is difficult to maintain or gain

altitude in single-engine emergencies. The one engine inoperative best

rate-of-climb speed is 104 KIAS with wing flaps and landing gear up. This speed

is indicated by a blue radial on the airspeed indicator. 

During postaccident interviews, the accident pilot stated that he was trained by Air

Sunshine that, in the event of an in-flight engine failure, a pilot should push ìall the engine

levers forward (throttle, mixture, and propeller levers).î As noted previously, the pilot

stated that his first action after he heard the bang and saw oil coming out of the right

engine cowling was to shut down the failed engine. The pilot stated that he did not follow

the companyís in-flight engine failure procedures because he knew which engine had

failed. The pilot added that he did not follow the in-flight engine failure checklist because

he was ìtoo busy flying the airplane.î The passenger in the copilot seat stated that the pilot

pushed the throttle, mixture, and propeller levers of the operative engine forward

immediately after he tried to shut down the failed engine. 

65 These procedures were also contained in Cessnaís 402C Aircraft Information Manual.
Factual Information 32 Aircraft Accident Report

Air Sunshineís Director of Operations, who is also a check captain and conducts

company training, stated that he trained pilots to perform the following procedures if an

in-flight engine failure occurred: (1) mixture [lever] ñ full forward, (2) propeller [lever] ñ

full forward, (3) throttles [lever] ñ full forward, (4) flaps ñ up [retracted], (5) gear ñ up

[retracted], (6) fuel selector ñ on main tanks, (7) auxiliary pump ñ on, (8) identify the

failed engine, (9) verify the failed engine, (10) feather the propeller, and (11) call for the

[engine failure] checklist.

1.17.1.2 Ditching Procedures

Air Sunshineís Training Manual, section 3, contained the following ditching

procedures:

Landing Gear ñ UP.

Approach ñ HEADWIND if high winds. PARALLEL to SWELLS if light wind

and heavy swells.

Wing Flaps ñ DOWN 45°.

Power ñ AS REQUIRED (300 Feet Per Minute Descent).

Airspeed ñ 95 KIAS minimum.

Attitude ñ DESCENT ATTITUDE through touchdown.

The pilot stated, during postaccident interviews, that he did not extend the flaps

before ditching.

1.17.1.3 Company Record-Keeping

1.17.1.3.1 Maintenance Records

 As noted previously, although Air Sunshineís Director of Maintenance told Safety

Board investigators that he and the assistant mechanic had repeated the compression

checks after initially getting unacceptably low readings (below 54 psi) for two of the right

engine cylinders (Nos. 2 and 4) during the airplaneís last scheduled engine maintenance in

June 2003, no documentation of the repeated checks was found. Further, no records were

found indicating that any inspections or corrective maintenance had been performed on

the right engine cylinders after getting the low compression check readings. As previously

mentioned, TCM SB 03-3 recommends that, if cylinder pressure levels are lower than the

limit established by the acceptable pressure leakage check (in this case, 54 psi), a cylinder

borescope inspection is to be conducted. In addition, no records were found indicating that

any of the right engine cylinders had been removed since the engine was last overhauled

(December 14, 1999).

A review of Air Sunshineís maintenance records revealed that the number stamped

on the No. 6 cylinder from the right engine did not match the number recorded in the

maintenance records; however, the maintenance records for the right engine did not
Factual Information 33 Aircraft Accident Report

indicate that the No. 6 cylinder had ever been removed or replaced. Air Sunshineís General

Manager stated that, according to company records, the cylinder installed in the No. 6

position on the accident airplane was a cylinder previously installed in the No. 3 position on

another one of the companyís engines, serial number 816113-R, which was installed on

N220RS. The General Manager stated that, from January to July 2001, engine serial

number 816113-R was not installed on N220RS and that, during that time, the engine ìwas

basically sitting in [the companyís] parts room.î He added that the No. 3 cylinder from

engine serial number 816113-R must have been installed on the accident engine at some

point during that time. However, the maintenance records for N220RS did not indicate that

the No. 3 cylinder had ever been removed or replaced from engine serial number 816113-R.

Further, a review of Air Sunshineís maintenance records revealed no reports to the FAA

that any of the companyís engines were running unsatisfactorily from the date that its

operations specifications were amended (September 9, 1999) to the date of the accident.66

1.17.1.3.2 Aircraft Flight Logs

A Safety Board review of the accident airplaneís flight logs from the first flight

conducted on December 23, 2002, to the last flight conducted on July 12, 2003, revealed

that the airplane had been operated a total of 543.8 hours on 559 flights. During this time,

pilots reported three maintenance-related discrepancies.

A review of the flight logs also revealed that the first flight to be conducted after

the last phase 1 check (June 14, 2003) occurred on June 16, 2003. From the June 16th

flight to the first flight conducted on the day of the accident, the airplane had been

operated a total of 79.7 hours on 83 flights. During this time, no pilot-reported

maintenance-related discrepancies were recorded. 

1.17.2 Federal Aviation Administration Oversight

1.17.2.1 General

Air Sunshine was initially certificated in 1982 by the Miami FSDO. The

companyís operations certificate was transferred to the Fort Lauderdale FSDO in 1986. As

noted previously, in early 1998, Air Sunshine asked the FAA to transfer its operations

certificate to the San Juan FSDO. The FAA granted the request, and the certificate was

transferred to the San Juan FSDO on June 2, 1998. 

According to the PMI for Air Sunshine, airplanes that are based at FLL are

maintained there, and airplanes that are based at SJU are maintained there. The PMI, who

is based in San Juan, reported that he scheduled three to four trips a year to FLL as part of

his work program. 

66 As noted previously, the PMI stated that he would grant Air Sunshineís request to amend its

operations specifications provided that the company monitored the performance of newly overhauled

engines and reported any abnormal conditions to the San Juan FSDO. 
Factual Information 34 Aircraft Accident Report

1.17.2.2 San Juan Flight Standards District Office Preaccident Oversight of 

Air Sunshine

According to the FAAís planned oversight program for Air Sunshine, the PMI

planned on conducting the following inspections for fiscal year 2003 (from October 1,

2002, to September 30, 2003): two required and two additional facility inspections at FLL,

two required and two additional ramp inspections of the Embraer 110 at FLL, two

required and two additional ramp inspections of the Cessna 402s at FLL, one required and

one additional spot check of the Cessna 402s at FLL, one required aircraft (Embraer 110)

records inspection and one additional aircraft records inspection at FLL, and one required

maintenance records inspection and one additional maintenance records inspection at SJU.

A review of FAA records indicated that, from October 1, 2002, to July 8, 2003, the PMI

conducted 10 ramp inspections, 2 spot inspections, and 1 aircraft records inspection.

The review of FAA records also indicated that the PMI conducted an inspection of

Air Sunshineís Fort Lauderdale facility from March 25 to 27, 2003. In an April 1, 2003,

letter to the company, the PMI stated that he found five Maintenance Manual-related

discrepancies during the inspection. The PMI also reported that he conducted an

inspection of Air Sunshineís San Juan facility from July 8 to 10, 2003. In a July 15, 2003,

letter to the company, the PMI stated that he found three Maintenance Manual- and three

aircraft records-related discrepancies. None of the aircraft records-related discrepancies

involved the accident airplane.

1.17.2.3 Fort Lauderdale Flight Standards District Office Postaccident 

Oversight of Air Sunshine

Although the Fort Lauderdale FSDO has no maintenance oversight responsibilities

for Air Sunshine, according to an aviation safety inspector from Fort Lauderdale, after the

accident, the Fort Lauderdale FSDO Manager contacted the San Juan FSDO Manager to

advise him that the Fort Lauderdale FSDO wanted to conduct additional surveillance of Air

Sunshine. A review of FAA records indicated that, from July 14 to September 30, 2003,

personnel from the Fort Lauderdale FSDO conducted 2 facility inspections, which found

scales that were out of calibration and cargo that was not secured; 21 ramp inspections,

which found numerous maintenance-related discrepancies with Air Sunshineís Cessna 402C

airplanes; and 5 spot inspections, which found numerous maintenance-related discrepancies. 

1.17.2.4 San Juan Flight Standards District Office Postaccident Oversight of 

Air Sunshine

According to the FAA, after the accident, the San Juan FSDO increased

surveillance of Air Sunshine in all areas. The FAA stated that, from July 14, 2003, to

February 25, 2004, the San Juan FSDO conducted 45 inspections of the company.

From July 22 to August 29, 2003, the San Juan FSDO conducted a focused

inspection of Air Sunshine. During this inspection, the FAA determined that the

companyís record-keeping system was inadequate, its maintenance program was deficient,

its passenger briefing card and overwater safety briefing needed to be revised, its pilot

training needed to be revised, and its engine compression check interval was too high. 
Factual Information 35 Aircraft Accident Report

The FAA stated that, as a result of these inspections, the following actions were taken:

ï The FAA filed an Enforcement Investigative Report regarding the deficiencies

found in Air Sunshineís record-keeping system. The FAA stated that

subsequent records inspections revealed that the deficiencies were corrected.

ï The FAA sent a letter to Air Sunshine, addressing all of the maintenance

discrepancies. The FAA stated that all of the corrective actions were

documented in its PTRS.

ï The FAA sent a letter to Air Sunshine, requiring the company to revise its

General Operations Manual, section 3 (relating to the passenger briefing card

and the overwater safety briefing). On October 1, 2003, the FAA accepted

revision No. 31, which amended the overwater safety briefing. On July 6, 2004,

the FAA accepted revision No. 32, which amended the passenger briefing card. 

ï The FAA sent a letter to Air Sunshine, requesting that the company revise its

FAA-approved Pilot Training Manual. On February 12, 2004, the FAA

accepted revision No. 15, which corrected outdated information and

training-hour requirements and conformed to the new format of FAA Order

8400.10, Air Transportation Operations Inspectorís Handbook. 

ï On November 18, 2003, Air Sunshine submitted and the FAA approved

revision No. 11 to Air Sunshineís AAIP, which lowered the compression check

interval from 360 to 120 hours. 

1.17.2.5 Additional Postaccident Actions

On February 26, 2004, Air Sunshineís PMI sent the company a letter regarding its

AAIP. The PMI stated that, effective immediately, the companyís Operations

Specification Part D-101 would be amended to specify that only TCM could rebuild the

companyís TCM TSIO-520-VB engines. The PMI further stated that, pending mitigating

actions on the part of Air Sunshine, he was proposing to reduce the TBO from 2,400 flight

hours to the manufacturer-recommended TBO of 1,600 flight hours, effective March 12,

2004. The PMI asked Air Sunshine to provide in writing, by March 4, 2004, a detailed

plan for any actions that the company planned on taking in response to the PMIís letter. 

In a letter to the FAA dated March 3, 2004, Air Sunshineís General Manager

responded that the company did not agree with the FAA that TCM rebuilt engines were

superior to engines that were overhauled by Airmark Overhaul. He added that Airmark

was a TCM distributor and that Airmark used TCM guidelines and ìbrand new

millennium cylinders.î67 He further stated that ìthroughout the years we have found

quality control and attention to details of Airmark highly superior to the mass production

errors inherent of large factories like TCM.î The manager asked the PMI to reconsider its

decision to require Air Sunshine to use only TCM rebuilt engines.

The General Manager stated that the company would revise its AAIP to include a

cylinder inspection every 1,600 flight hours, which would include replacement of valves,

67 ìMillenniumî cylinders are Superior Air Parts cylinders. Five of the six cylinders from the right

engine were ECI cylinders.
Factual Information 36 Aircraft Accident Report

rings, and gaskets. The manager also stated that the cylinder inspection would include, if

necessary, replacement of valve seats, guides, and pistons. He added that the company

would revise its compression check interval and place additional constraints, such as

replacing of cylinders if the compression levels fell below the limit established in

accordance with TCM SB 03-3. The manager stated that the company had already revised

its AAIP to require three compression checks during a 360-flight-hour inspection cycle

(compression checks would be conducted once every 120 flight hours). At the time of the

accident, one compression check was required during a complete inspection cycle

(compression checks were conducted once every 360 hours).

The General Manager stated that Air Sunshine was also willing to conduct

cylinder inspections on the four engines in its fleet that had more than 1,600 flight hours

and that the company had already ordered one new TCM engine to replace an engine that

had about 2,200 flight hours. The manager also stated that the company had followed all

of the guidelines to obtain the TBO extension to 2,400 flight hours, including preparing

five engine teardown reports, and that the company had operated for 11 years and for more

than 100,000 flight hours under the extended TBO.

1.18 Additional Information

1.18.1 Previous Ditching Accidents

On January 1, 2002, a Piper PA-31 operated by Air Taxi, Inc., as a Part 135

nonscheduled commuter flight was ditched in the Atlantic Ocean after fuel exhaustion.

Three passengers and the pilot sustained serious injuries, and one passenger died.

According to the surviving passengers, the pilot did not conduct a preflight briefing or an

emergency briefing before the ditching. Four of the PFDs on board the airplane were

retrieved after the airplane was in the water.68

On August 20, 2000, a Piper PA-31 operated by Big Island Air as a Part 135

commuter flight was ditched in the Pacific Ocean after a loss of engine power. All of the

passengers retrieved their PFDs before the ditching. The passengers reported that, shortly

after the engine problem occurred, the pilot instructed them to retrieve and don their PFDs

and assume a crash position. One passenger retrieved, donned, and partially inflated her

PFD, but she was not able to evacuate the airplane and, as a result, died. 

68 A description of this accident, MIA04FA48, can be found on the Safety Boardís Web site at

<http://www.ntsb.gov>.
37 Aircraft Accident Report

2. Analysis

2.1 General

The pilot was properly certificated and qualified under Federal regulations. No

evidence indicated any preexisting medical or physical condition that might have

adversely affected the pilotís performance during the accident flight.

The airplane was properly certificated and equipped in accordance with Federal

regulations. The airplane was equipped with FAA-approved flotation gear, as required by

Federal regulations. 

The airplane was loaded in accordance with FAA-approved company weight and

balance procedures. The weight and balance of the airplane were within prescribed limits

during all phases of the flight.

Given the distance from shore at which the ditching occurred and the availability

of emergency response equipment, the search and rescue efforts were timely and

appropriate. The accident was survivable.69 

The inoperative distance measuring equipment on the MYAT VOR was not a

factor in this accident.

This analysis discusses the accident sequence, including the airplaneís

performance after the right engine failed and the cause of this failure. This analysis also

discusses Air Sunshine-related maintenance issues, pilot proficiency, and the need for

emergency briefings.

2.2 Accident Sequence

The accident flight departed FLL about 1427. The takeoff and cruise portions of

the flight were uneventful. The pilot reported that the flightís cruise altitude was about

7,500 feet and that the cruise speed was about 160 KIAS.

The pilot reported that, while descending through an altitude of about 3,500 feet at

an airspeed of about 135 to 140 KIAS and a distance of about 20 to 25 miles from MYAT,

he heard a bang and saw oil coming out of the right engine cowling. Several of the

passengers reported seeing white smoke coming from the engine followed by a stream of

oil and then hearing a loud bang. The passengers reported seeing parts falling from the

69 Although the accident was survivable, two passengers died after evacuating the airplane. Section 2.9

discusses the pilotís failure to conduct an emergency briefing after the right engine failed and this failureís

effect on the outcome of the accident.
Analysis 38 Aircraft Accident Report

engine after they heard the loud bang. The pilot reported that, after attempting to shut

down the right engine, he applied full power to the left engine and slowed to about 95 KIAS,

but he could not maintain altitude. He stated that, once the airplane descended through an

altitude of about 1,500 to 1,000 feet, he realized that the airplane could not make it to the

airport and, therefore, he decided to ditch the airplane.

The on-site examination of the airplane after it was recovered from the water

revealed that both of the right engine magnetos had penetrated through the engine cowling

and that they were hanging onto the engine by their harnesses. After opening the engine

cowling, the No. 2 cylinder was found separated from the engine crankcase at the cylinder

flange. Therefore, the Safety Board concludes that the airplaneís right engine failed while

the airplane was descending through an altitude of about 3,500 feet. 

2.3 Airplane Performance After the Right Engine Failure

Air Sunshineís Training Manual states that, if a failed engine does not start after

performing steps 1 through 8 of the in-flight engine failure procedures (see section 1.17.1.1),

the pilot should close the throttle, cut off mixture, and feather the propeller on the

inoperative engine; move the fuel selector, auxiliary fuel pump, and magneto switches for

the inoperative engine to off; and close the cowl flaps. The left fuel selector valve in the

cockpit was found positioned to the left main fuel tank; the position of the right fuel selector

valve was not determined. The right cowl flap was found open. Further, Air Sunshineís

Training Manual states that, before ditching, the pilot should extend the wing flaps to 45°.

The pilot stated that he did not extend the flaps before ditching; however, the Safety Board

notes that the airplane was found with the left and right flaps extended to 15°.70

Several factors existed that adversely affected the airplaneís performance,

including the windmilling propeller (-400 fpm penalty), the protruding magnetos (-4 fpm

penalty), and the open right engine cowl flap (-9 fpm penalty). In addition, flaps that are

extended to 15° could cause a -145 to -165 fpm penalty. However, Safety Board

investigators could not determine when the flaps were extended; therefore, it is unknown

when the penalty for flaps at 15° started.

Several other factors could also have degraded the airplaneís performance,

including not flying at the recommended airspeeds, operating with a bank angle and

sideslip not in accordance with Cessnaís recommended in-flight engine failure

configuration, and not maintaining a steady descent. However, Cessna could not quantify

the penalties for these variables. The Safety Board calculated that, at an airspeed of

90 knots and with the engine damage, the airplane could have tolerated a descent rate of

about 250 fpm and have been able to maintain flight and reach land. The pilot stated that,

during the ditching, the descent rate was between about 200 and 300 fpm. Board

calculations showed that the airplaneís descent rate was between 560 and 212 fpm during

its descent from 3,500 feet to 2,000 feet and was between 429 and 360 fpm during its

descent from 2,000 feet to contact with the water.

70 The pilot stated that one of the passengers might have hit the electrically controlled switch that

extends the flaps while they were evacuating the airplane. 
Analysis 39 Aircraft Accident Report

On the basis of this evidence, the Safety Board concludes that several factors

contributed to the degradation of the airplaneís performance and its inability to maintain

flight and reach land, including the windmilling propeller, the protruding magnetos, the open

right engine cowl flap, and the possibility that the flaps were extended to 15° at some point

during the descent. The Safety Board further concludes that, during the descent from 3,500

to 2,000 feet, the airplaneís descent rate was between about 560 and 212 fpm, and that,

during the descent from 2,000 feet to contact with the water, its descent rate was between

429 and 360 fpm. The Safety Board also concludes that, if the average descent rate had been

about 200 fpm or less, the airplane would have been able to maintain flight and reach MYAT. 

The pilot stated that, when he tried to feather the right propeller, it continued to turn

until the airplane contacted the water. Two passengers stated that the propeller continued

turning until the airplane contacted the water. However, when the propeller was removed

and examined, the blade angles were measured to be within the specified range for feather

(82.2° +/-0.3°). Further, the propellerís start-lock mechanism showed no evidence of

damage, such as witness marks, which would have been expected if the propeller had been

on the start locks at the time that it contacted the water. Therefore, the Safety Board

concludes that the right propeller was in the fully feathered position, but Board

investigators could not determine at what point the propeller became fully feathered. 

2.4 Right Engine Failure Sequence

Previous Safety Board investigations of engine cylinder separations have shown

that cylinder stud failures generally occurred as a progressive sequence of fatigue

fractures. Typically, the initial fracture has been caused by high-cycle, low-stress fatigue

(indicating preexisting cracking that was not created during the engine cylinder

separation) and has penetrated nearly the entire fastener section. Subsequent fractures

have shown decreasing amounts of fatigue followed by overstress and fracture features

that were increasingly indicative of high-stress propagation. However, the accident

airplane right engine No. 2 cylinder stud fractures showed no evidence of a progressive

sequence of fatigue, indicating that a sudden onset of higher loads occurred. 

Although combustion instabilities, such as detonation or preignition, can cause the

rapid increase of the loads on the studs, no evidence of such an event was found. A partial

piston or ring failure can also increase the loads on the studs; however, metallurgical

evidence indicated that the No. 2 cylinder piston fractures were caused by sudden

overstress. Optical examinations of the fractured studs and through bolts confirmed that

they failed as a result of high-stress fatigue.

Small, raised ridges observed on the forward side of the right engine No. 2

cylinder mounting face indicated that the cylinder was rocking on the engine crankcase,

pivoting around the through bolt on the forward side of the base flange. For this motion to

occur, some of the cylinder studs opposite of this location had to become fractured or the

nuts opposite of this location had to become loose. Two of the studs from this area were

found intact but without the nuts.
Analysis 40 Aircraft Accident Report

In addition, two intact cylinder hold-down nuts were found in the engine

compartment area. Typically, cylinder hold-down nuts become separated from the cylinder

hold-down studs if the threads on the nuts or studs are stripped (pulled out) or if the nuts

become loose and unthreaded by vibration. The threads on the two cylinder hold-down

nuts found in the engine compartment area were intact; the damage to the threads of the

nonfractured studs in the engine crankcase was minimal. Therefore, the hold-down nuts

on the two unfractured studs must have become loose and backed off of the studs. The

Safety Board is unaware of any previous instances of cylinder separations in which the

hold-down nuts completely backed off of multiple studs. 

 The loss of the cylinder hold-down nuts on the two unfractured studs would have

caused the loads to be transferred to the remaining studs and through bolts. The increased

load would have been sufficient to initiate and propagate high-stress fatigue fractures in

four of the remaining studs and both through bolts; the loads on the remaining stud would

have been sufficient to strip its case threads. The presence of fractures of the four broken

studs, the fractures of the two broken through bolts, and the stripped case threads at

another stud location indicated that the nuts were present on these studs and through bolts

for a significant portion of the failure sequence.

Several sharp circumferential dents, scrapes, and other contact marks on the bore

portion of the case that mates with the No. 2 cylinder skirt show that the failure of the

No. 2 cylinder retention system caused the progressive outboard movement of the

cylinder. At some point, the piston fragmented and, the connecting rod, wrist pin, and

piston fragments separated from the engine. 

On the basis of the metallurgical evidence, the Safety Board concludes that two or

more of the right engine No. 2 cylinder hold-down nuts became loose and backed off of

the studs, which resulted in the remaining studs and through bolts fracturing in high-stress

fatigue, allowing the cylinder to separate from the engine. 

2.5 Cause of the Loosened No. 2 Cylinder Hold-down 

Nuts

The probability that two or more cylinder hold-down nuts would simultaneously

loosen is very low. Therefore, an outside influence, such as the application of insufficient

torque to the nuts during maintenance, likely occurred. The Safety Board reviewed Air

Sunshineís maintenance records to determine when insufficient torque might have been

applied to the nuts. 

Between the time of the last compression checks (June 12 to 14, 2003) and the

accident, the engine accumulated 83 flight hours. No records were found indicating that

any other maintenance was performed on the accident engine at the time of and after the

last compression check. Although it is possible that insufficient torque was applied to the

cylinder hold-down nuts during undocumented maintenance at the time of the last known
Analysis 41 Aircraft Accident Report

maintenance event,71 it is also possible that insufficient torque was applied during

undocumented maintenance subsequent to the last known event. However, if a mechanic

does not apply enough torque to a nut during maintenance, the nut typically becomes loose

soon afterward. Therefore, the Safety Board concludes that the simultaneous loosening of

two or more of the right engine No. 2 cylinder hold-down nuts resulted from the

application of insufficient torque, which was applied by Air Sunshine maintenance

personnel during undocumented maintenance.

2.6 Air Sunshine Maintenance Record-Keeping and 

Practices

The Safety Boardís review of Air Sunshineís maintenance records revealed several

discrepancies. The review revealed that the number stamped on the No. 6 cylinder from

the accident airplaneís right engine did not match the number recorded in the maintenance

records. The maintenance records for the right engine did not indicate that the No. 6

cylinder had ever been removed or replaced. Further, although the companyís General

Manager reported that the No. 6 cylinder was originally the No. 3 cylinder from another

one of the companyís engines, the maintenance records for the other engine did not

indicate that its No. 3 cylinder had ever been removed or replaced. Air Sunshineís records

showed no evidence that the company had reported any problems with its engine to the

FAA72 despite evidence found during this investigation that indicated that at least two

cylinders were removed and replaced on two separate engines. 

In 1998, Air Sunshine applied to change its AAIP from a 3-phase, 60-hour

inspection program to a 6-phase, 60-hour inspection program. The FAA approved the

change, which was in effect at the time of the accident. As a result of this change, engine

differential compression checks were conducted once every 360 hours instead of every

180 hours. Subsequent to the accident, Air Sunshine changed its AAIP to require that

three compression checks be conducted during a 360-hour inspection cycle (once every

120 hours), and the FAA approved this change. Although the companyís modified AAIP

increased the number of compression checks in a 360-hour cycle, the compression check

interval is still well beyond the 100-hour interval recommended in SB 03-3. 

In addition, during the last differential compression checks performed on the

airplaneís engines (from June 12 to 14, 2003), the assistant mechanic recorded readings of

0 psi for the right engine No. 2 cylinder and 20 psi for the No. 4 cylinder. Further, Safety

Board investigators who reviewed the engine differential compression check form on

which the assistant mechanic recorded the readings noted that the number recorded for the

71 Typically, torque only needs to be applied to cylinder hold-down nuts after cylinder installations.

Cylinders are not removed and reinstalled during compression checks; therefore, insufficient torque would

not have been applied during the June 2003 compression checks.

72 As noted previously, in a September 9, 1999, letter to Air Sunshine, the PMI stated that he would

grant the companyís request to amend its operations specifications to reflect the 2,400-flight-hour TBO if

the company monitored the performance of newly overhauled engines and reported any abnormal conditions

to the San Juan FSDO.
Analysis 42 Aircraft Accident Report

No. 3 cylinder could have been either 55 or 25. The Director of Maintenance told Safety

Board investigators that, because the readings were low, he repeated the checks on all of

the right engine cylinders. He stated that all of the readings were in the 70-psi range.

However, Board investigators could not find any documentation indicating that the checks

had been repeated. 

The differential compression checks on the right engine were performed by an

assistant mechanic without supervision or assistance, even though he did not have an A&P

certificate. During postaccident interviews, the assistant mechanic stated that he had never

conducted a compression check before conducting the checks on the accident airplaneís

right engine. When a Safety Board investigator asked the assistant how to perform the test,

he did not appear to be familiar with the entire test. Further, Air Sunshineís Maintenance

Manual contained a caution, stating that two people should conduct the compression checks.

The Safety Board notes that, for the compression checks to be conducted safely and

properly, the two people who conduct the checks should have adequate training and

experience. However, Air Sunshineís Director of Maintenance allowed a non-A&P

certified assistant mechanic, who had never previously performed engine compression

checks, to perform the checks by himself without supervision. Further, a review of the

assistant mechanicís training records indicated that he did not complete on-the-job training

for the entire airplane until 14 to 16 days after he performed the compression checks. The

assistant mechanic should not have been working unsupervised during on-the-job training,

which indicated that the companyís on-the-job maintenance training was not adequate.

Last, during postaccident interviews, the Director of Maintenance stated that,

when company maintenance personnel remove and replace an engine cylinder assembly,

they coat the cylinder hold-down studs with an aluminum-copper-graphite, lithium-based

antiseize compound manufactured by Permatex before applying torque to the studs. The

use of the Permatex compound is not in accordance with TCM SB 96-7B. Permatex does

not recommend using antiseize compound in high-vibration environments because it

could contribute to the loss of torque. Although the threads of the right engine studs and

through bolts showed no evidence of this compound, the Safety Board is concerned that

Air Sunshine indicated that it was using an antiseize compound on its engines. The Safety

Board concludes that, at the time of the accident, Air Sunshineís maintenance

record-keeping and practices were not adequate. 

Subsequent to the accident, the FAA conducted a focused inspection of Air

Sunshine (from July 22 to August 29, 2003). During these inspections, the FAA

determined that the companyís maintenance program was deficient. The FAA stated that it

had sent a letter to Air Sunshine in which all of the maintenance discrepancies were

addressed and that all of the companyís corrective actions in response to these

discrepancies had been documented in the FAAís PTRS. Therefore, the Safety Board

concludes that the FAAís oversight of Air Sunshine was in accordance with standard

guidelines, but was insufficient to detect inadequate maintenance record-keeping and

practices at the company.
Analysis 43 Aircraft Accident Report

2.7 Pilot Proficiency 

A review of Arrow Airís simulator training records for the pilot revealed that he

had received a large number of ìunsatisfactoryî grades and that he needed to improve his

scanning and checklist skills, including response and organization.73 Further, on

September 13, 2000, the pilot failed a ramp check because an FAA inspector found that

the airplane had numerous discrepancies and that his passenger briefing was inadequate. 

Airplane performance calculations show that the windmilling propeller and the

protruding magnetos alone were not sufficient to cause the airplane to descend as rapidly

as it did. Other factors that were most likely caused or controlled by the pilot, including

not flying at the recommended airspeeds and flap settings, operating with a bank angle and

sideslip that were not in accordance with Cessnaís recommended in-flight engine failure

configuration, and not maintaining a steady descent, could have degraded the accident

airplaneís performance. If the pilot had been more proficient, he might have been able to

decrease the descent rate enough to maintain flight and reach land.

A review of FAA records revealed that, from April 1983 to February 1998, the

pilot failed nine flight checks. The pilot failed two flight checks that he was receiving for

his private pilot certificate, one flight check that he was receiving for his instrument pilot

rating, one flight check that he was receiving for his ATP certificate, two flight checks that

he was receiving for his CFI certificate, and three flight checks that he was receiving for

his CFI instrument rating.

Therefore, the Safety Board concludes that the pilot had a history of

below-average flight proficiency, including numerous failed flight tests, before the

accident flight, which contributed to his inability to maintain maximum flight

performance and reach land after the right engine failed.

2.8 Pilot Failure to Use Shoulder Harness

Federal regulations require flight crewmembers of U.S.-registered civil aircraft to

keep their shoulder harnesses fastened during takeoff and landing, including during a

ditching. During postaccident interviews, the pilot stated that he did not have his shoulder

harness fastened during the ditching. He added that, because his harness was not fastened,

he hit his head on the instrument panel when the airplane hit the water, which made him

dizzy. Two passengers indicated that the pilot was incoherent when he was in the water.

One of the passengers also stated that the pilot ìdid not look like he could swimî and that

he had to give the pilot his PFD. Therefore, the Safety Board concludes that the pilot was

not wearing his shoulder harness during the ditching, and, because he was not wearing his

harness, he sustained a head injury that reduced his ability to assist passengers after the

ditching. 

73 The pilot did not complete Arrow Airís pilot training program.
Analysis 44 Aircraft Accident Report

2.9 Emergency Briefings

Air Sunshineís FAA-approved General Operations Manual stated that, before a

ditching, the pilot should review the emergency ditching evacuation procedures with the

passengers and instruct them to don their PFDs without inflating them in the airplane. The

manual added that the pilot should also review with the passengers how to operate the

PFDs. Because these instructions were also contained in the companyís operations

specifications, the instructions were required to be performed by the pilot. 

In a 1985 safety study titled, Air Carrier Overwater Emergency Equipment and

Procedures,74 the Safety Board concluded that ìthe ability of flight and cabin

crewmembers to assist passengers effectively during ditchings and following inadvertent

water impacts may be the single most important factor in the survival outcome.î As noted

previously, passengers reported that, after the right engine failed, the pilot did not tell them

to retrieve or don their PFDs before the airplane contacted the water. The passengers

stated that the only time the pilot addressed them after the right engine failed and before

the airplane contacted the water was to tell them to ìcalm down.î 

According to the Safety Boardís airplane performance study, the airplane was

airborne for at least 7 minutes after the right engine failed and before it contacted the

water. Even though the pilot did not instruct the passengers to retrieve their PFDs, the

passenger in seat 3B, who was holding a child on her lap, retrieved the PFD from under

her seat, and the passenger in seat 5A retrieved three PFDs and put them on the children

accompanying her. None of the other passengers or the pilot attempted to retrieve their

PFDs before the airplane contacted the water. After the airplane was in the water, several

of these passengers tried to retrieve their PFDs, but none was successful. 

If the pilot had instructed the adult passengers to retrieve and don their PFDs and

had reviewed how to operate the PFDs shortly after the right engine failed, all of the

passengers would have had adequate time to retrieve and don their PFDs before the

airplane contacted the water. The Safety Board is aware that, subsequent to the accident,

Air Sunshine amended its emergency ditching procedures by adding the instruction that all

occupants should don PFDs as soon as any emergency occurs during overwater

operations.

 The Safety Board concludes that, after determining that he was going to ditch the

airplane, the pilot failed to conduct an emergency briefing, which was required by the

emergency ditching procedures contained in Air Sunshineís General Operations Manual,

and that this failure contributed to passenger fatalities. The Safety Board further concludes

that the passengers would have had sufficient time to retrieve and don their PFDs if the

pilot had instructed them to do so shortly after the right engine failed. 

74 For more information, see National Transportation Safety Board, Air Carrier Overwater Emergency

Equipment and Procedures, Safety Study NTSB/SS-85/02 (Washington, DC: NTSB, 1985).
Analysis 45 Aircraft Accident Report

On January 1, 2002, a Piper PA-31 operated by Air Taxi, Inc., was ditched in the

Atlantic Ocean after fuel exhaustion. Three passengers and the pilot sustained serious

injuries, and one passenger died. According to the surviving passengers, the pilot did not

conduct a preflight briefing or an emergency briefing before the ditching. None of the

PFDs on board the airplane were retrieved until the airplane was in the water. 

In contrast, on August 20, 2000, a Piper PA-31 operated by Big Island Air was

ditched in the Pacific Ocean after a loss of engine power. All of the passengers retrieved

their PFDs before the ditching. The passengers reported that, shortly after the engine

problem occurred, the pilot instructed them to retrieve and don their PFDs and assume a

crash position. As indicated by this event, if passengers aboard flights that operate over

water are adequately briefed and have time to prepare during an emergency, deaths may be

prevented. 

The Safety Board concludes that having pilots provide adequate emergency

briefings to passengers is an important survival factor. Therefore, the Safety Board

believes that the FAA should issue a flight standards information bulletin to principal

operations inspectors of all Part 135 single-pilot operators that carry passengers and

operate over water, which familiarizes them with the circumstances of the Air Sunshine

flight 527 accident and emphasizes the need for pilots to provide timely emergency

briefings. The bulletin should state that these briefings should include, at a minimum,

information about the location and operation of the on-board emergency equipment and

exits. 
46 Aircraft Accident Report

3. Conclusions

3.1 Findings

1. The pilot was properly certificated and qualified under Federal regulations. No

evidence indicated any preexisting medical or physical condition that might have

adversely affected the pilotís performance during the accident flight.

2. The airplane was properly certificated and equipped in accordance with Federal

regulations. The airplane was equipped with Federal Aviation

Administration-approved flotation gear, as required by Federal regulations.

3. The accident airplane was loaded in accordance with Federal Aviation

Administration-approved company weight and balance procedures. The weight and

balance of the airplane were within prescribed limits during all phases of the flight.

4. Given the distance from shore at which the ditching occurred and the availability of

emergency response equipment, the search and rescue efforts were timely and

appropriate. The accident was survivable.

5. The inoperative distance measuring equipment on the Treasure Cay Airport very high

frequency omnidirectional range was not a factor in this accident.

6. The airplaneís right engine failed while the airplane was descending through an

altitude of about 3,500 feet.

7. Several factors contributed to the degradation of the airplaneís performance and its

inability to maintain flight and reach land, including the windmilling propeller, the

protruding magnetos, the open right engine cowl flap, and the possibility that the flaps

were extended to 15° at some point during the descent.

8. During the descent from 3,500 to 2,000 feet, the airplaneís descent rate was between

about 560 and 212 feet per minute (fpm), and, during the descent from 2,000 feet to

contact with the water, its descent rate was between 429 and 360 fpm.

9. If the average descent rate had been about 200 feet per minute or less, the airplane

would have been able to maintain flight and reach Treasure Cay Airport.

10. The right propeller was in the fully feathered position, but Safety Board investigators

could not determine at what point the propeller became fully feathered.

11. Two or more of the right engine No. 2 cylinder hold-down nuts became loose and

backed off of the studs, which resulted in the remaining studs and through bolts

fracturing in high-stress fatigue, allowing the cylinder to separate from the engine. 
Conclusions 47 Aircraft Accident Report

12. The simultaneous loosening of two or more of the right engine No. 2 cylinder

hold-down nuts resulted from the application of insufficient torque, which was

applied by Air Sunshine maintenance personnel during undocumented maintenance.

13. At the time of the accident, Air Sunshineís maintenance record-keeping and practices

were not adequate.

14. The Federal Aviation Administrationís oversight of Air Sunshine was in accordance

with standard guidelines, but was insufficient to detect inadequate maintenance

record-keeping and practices at the company.

15. The pilot had a history of below-average flight proficiency, including numerous failed

flight tests, before the accident flight, which contributed to his inability to maintain

maximum flight performance and reach land after the right engine failed.

16. The pilot was not wearing his shoulder harness during the ditching, and because he

was not wearing his harness, he sustained a head injury that reduced his ability to

assist passengers after the ditching.

17. After determining that he was going to ditch the airplane, the pilot failed to conduct

an emergency briefing, which was required by the emergency ditching procedures

contained in Air Sunshineís General Operations Manual, and this failure contributed

to passenger fatalities. 

18. The passengers would have had sufficient time to retrieve and don their personal

flotation devices if the pilot had instructed them to do so shortly after the right engine

failed. 

19. Having pilots provide adequate emergency briefings to passengers is an important

survival factor.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the in-flight failure of the right engine and the pilotís failure to

adequately manage the airplaneís performance after the engine failed. The right engine

failure resulted from inadequate maintenance that was performed by Air Sunshineís

maintenance personnel during undocumented maintenance. Contributing to the passenger

fatalities was the pilotís failure to provide an emergency briefing after the right engine

failed. 
48 Aircraft Accident Report

4. Recommendation

As a result of its investigation of the July 13, 2003, Air Sunshine flight 527

accident, the National Transportation Safety Board makes the following recommendation

to the Federal Aviation Administration:

Issue a flight standards information bulletin to principal operations

inspectors of all Part 135 single-pilot operators that carry passengers and

operate over water, which familiarizes them with the circumstances of the

Air Sunshine flight 527 accident and emphasizes the need for pilots to

provide timely emergency briefings. The bulletin should state that these

briefings should include, at a minimum, information about the location and

operation of the on-board emergency equipment and exits. (A-04-55)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN ENGLEMAN CONNERS

Chairman

CAROL J. CARMODY

Member

MARK V. ROSENKER

Vice Chairman

RICHARD F. HEALING

Member

DEBORAH A. P. HERSMAN

Member

Adopted: October 13, 2004
49 Aircraft Accident Report

5. Appendix

Appendix A

Investigation and Public Hearing

Investigation

The National Transportation Safety Board learned about the accident about 1545

on July 13, 2003. A go-team was not assembled, and the Safety Board did not immediately

respond to the scene of the accident. An Air Safety Investigator from the Boardís Southeast

Regional Field Office departed Miami on July 31, 2003, to observe the recovery of the

airplane, which occurred on August 3, 2003, about 1120. Investigators from Cessna Aircraft

Company and the Federal Aviation Administration (FAA) were also present during the

recovery.

Parties to the investigation were the FAA, Teledyne Continental Motors, McCauley

Propeller Systems, and Cessna Aircraft Company. The Bahamian Government designated

an accredited representative to assist in the investigation.

Public Hearing

No public hearing was held for this accident.