Investigation Summary
The accident originated from a material failure in the #2 (right) engine. Two high-pressure turbine blades fractured due to stress rupture caused by oxidation and corrosion, a condition the NTSB noted was exacerbated by the airline's inadequate maintenance oversight. Although the crew initially identified the right engine failure correctly during the climb, the situation deteriorated when they leveled off at 2,000 feet. The first officer, acting as Pilot Flying, reduced thrust on both engines to maintain speed, but the left (healthy) engine responded more quickly to the throttle reduction than the damaged right engine. This led the first officer to believe the left engine was 'gone' because its Engine Pressure Ratio (EPR) was lower. The captain, preoccupied with air traffic control communications, did not cross-check the engine instruments and accepted the first officer's incorrect diagnosis. For the remainder of the flight, the crew attempted to fly using the damaged right engine, which was operating with high exhaust gas temperatures (EGT) and eventually failed completely, while the healthy left engine sat at idle. The NTSB highlighted that the captain's delay in starting the Engine Failure or Shutdown checklist prevented the crew from systematically identifying the correct engine.
Final Conclusions
The NTSB determined the probable cause was the flight crew's misidentification of the damaged engine and their use of only the damaged engine for thrust, resulting in an unintentional descent and ditching. Contributing factors included ineffective crew resource management (CRM), high workload, and stress. The investigation also revealed significant maintenance deficiencies at Rhoades Aviation, leading the FAA to revoke the airline's air operator certificate in May 2022.
Photographic Evidence (1)
Video Analysis
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Airframe & Maintenance
Crew Experience
Captain
Had 10,600 hours of PIC time.
First Officer
Systems & Failure Modes
Pratt & Whitney JT8D-9A Engines
Low-bypass turbofan engines; the right engine suffered oxidation and corrosion in the high-pressure turbine blades, leading to stress fractures.
EPR Gauges
Engine Pressure Ratio gauges were the primary power indicators; a lower reading on the healthy engine during throttle reduction contributed to the crew's confusion.
Interesting Facts
- 01The aircraft was a 46-year-old Boeing 737-200 cargo conversion.
- 02Both pilots survived the ditching; the captain sustained serious injuries and the first officer sustained minor injuries.
- 03The wreckage was located at a depth of 360 to 420 feet, requiring ROVs for recovery.
- 04The right engine had over 101,000 cycles at the time of the accident, significantly more than the airframe's 69,446 cycles.
- 05The FAA revoked the operator's certificate (Rhoades Aviation) following the investigation.
Safety Actions & Advisories
FAA Certificate Revocation
On May 25, 2022, the FAA revoked Rhoades Aviation's air operator certificate, citing 33 flights conducted with engines that were not airworthy and other safety violations.
Location
ACCIDENT SITE · Coordinates taken from the entered by an editor.