What happened
While performing flight inspection equipment checks, an aircraft entered a holding pattern within an area of forecasted moderate icing. During this period, the crew observed ice accumulating on the airframe and subsequently activated the surface de-icing system. The action caused accumulated ice to break free and enter the engine intakes, resulting in both engines suffering flameouts.
Following the loss of power, the crew attempted to restart the engines during an emergency descent, but neither engine was able to maintain power. The pilots requested vectors toward a more distant airport before the aircraft impacted trees. Investigations confirmed that both engines sustained compressor damage consistent with foreign object damage from ice ingestion. No other mechanical or system malfunctions were identified on the aircraft.
Findings
The investigation determined that the primary cause was the failure of the pilot in command to notice rapid ice accumulation because his attention was diverted. Several contributing factors were identified, including the crew's delayed response to ice removal and the psychological states of both pilots.
Additional findings noted:
- The co-pilot had received insufficient training regarding flight inspection procedures.
- The pilot in command was experiencing significant personal stress during the period leading up to the accident.
- There were concerns regarding the crew's recent activities and physiological condition, noting that the captain had a blood alcohol level of 0.057% at the time of death, though putrefaction may have influenced this measurement.
- Organizational issues within the FAA, specifically regarding inadequate surveillance and insufficient staffing, were also cited as contributing factors.