19990521042049A

Accident · Substantial damage

FAA accident report · Cessna 414 · Orland, CA · May 21, 1999

Date
May 21, 1999 · 17:25 local
Place
Orland, CA
Airport
Haigh Field Airport
Phase of flight
Fcd/Prec Ldg From Cruise
Operating rules
General operating rules (Part 91)
Operator
URSA
Damage
Substantial damage
Aircraft
N8153Q
NTSB investigation
NTSBLAX99LA188
Reported as
Cessna 414
Reported engine
Continental IO520*
Fatal injuries
0
Pilot’s flight hours
12,000 total480 in this make and model136 in the last 90 days

From the FAA’s Accident/Incident Data System (AIDS), through its Aviation Safety Information Portal, as reported. The NTSB investigates accidents separately, and its record of an accident is the fuller one. The aircraft is matched to the registry by N-number and event date, checked against the reported make and model; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

What happened

The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.

(-23) Aircraft landed short of runway after experiencing engine failure on both engines. (.4)the pilot refueled the auxiliary tanks of the airplane at a different airport 1 month prior to the accident, and had not flown on the auxiliary tanks since that time. He was repositioning the airplane back to home base after a series of revenue flights when the accident occurred. About 20 minutes after takeoff he positioned the left and right engines to their respective auxiliary fuel tanks, and then returned to the mains 30 minutes later. The right engine began to surge and subsequently stopped running. Turning on the fuel boost pump restarted the engine. Five minutes later the engine quit and he secured it after unsuccessful restart attempts. Then the left engine began to surge and was developing only partial power. He diverted to an alternate airport with decaying altitude and power in the remaining engine. Crossing the airport, he saw he was too high to land with a tailwind so he circled to land into the wind. On the base leg he made the decision to land straight ahead in a field due to power lines in his path, rapidl y decaying altitude, and power. The left and right main fuel filters contained a foreign substance, which upon laboratory examination, was found to be a polyacrylamide. This is a manmade synithetic polymer that is used as an agricultural soil amendment that aids in reducing soil ersion. Distribution of the polymer is typically not done by aircraft. Inspection of the fueling facility revealed that the employees who do refueling did not have any formal or on-the-job training. There was no record that the delivery system filters had been examined or changed. The maintenance to the truck, delivery system, and storage facility are done by the employees on an as needed, time permitted basis. The fuel truck was found to be impropertly labeled, and the fuel nozzle was lying in a compartment amid dirt, gravel, and other contaminated with no caps or covers for protection.

As the FAA filed it

(-23) AIRCRAFT LANDED SHORT OF RUNWAY AFTER EXPERIENCING ENGINE FAILURE ON BOTH ENGINES. (.4)THE PILOT REFUELED THE AUXILIARY TANKS OF THE AIRPLANE AT A DIFFERENT AIRPORT 1 MONTH PRIOR TO THE ACCIDENT, AND HAD NOT FLOWN ON THE AUXILIARY TANKS SINCE THAT TIME. HE WAS REPOSITIONING THE AIRPLANE BACK TO HOME BASE AFTER A SERIES OF REVENUE FLIGHTS WHEN THE ACCIDENT OCCURRED. ABOUT 20 MINUTES AFTER TAKEOFF HE POSITIONED THE LEFT AND RIGHT ENGINES TO THEIR RESPECTIVE AUXILIARY FUEL TANKS, AND THEN RETURNED TO THE MAINS 30 MINUTES LATER. THE RIGHT ENGINE BEGAN TO SURGE AND SUBSEQUENTLY STOPPED RUNNING. TURNING ON THE FUEL BOOST PUMP RESTARTED THE ENGINE. FIVE MINUTES LATER THE ENGINE QUIT AND HE SECURED IT AFTER UNSUCCESSFUL RESTART ATTEMPTS. THEN THE LEFT ENGINE BEGAN TO SURGE AND WAS DEVELOPING ONLY PARTIAL POWER. HE DIVERTED TO AN ALTERNATE AIRPORT WITH DECAYING ALTITUDE AND POWER IN THE REMAINING ENGINE. CROSSING THE AIRPORT, HE SAW HE WAS TOO HIGH TO LAND WITH A TAILWIND SO HE CIRCLED TO LAND INTO THE WIND. ON THE BASE LEG HE MADE THE DECISION TO LAND STRAIGHT AHEAD IN A FIELD DUE TO POWER LINES IN HIS PATH, RAPIDL Y DECAYING ALTITUDE, AND POWER. THE LEFT AND RIGHT MAIN FUEL FILTERS CONTAINED A FOREIGN SUBSTANCE, WHICH UPON LABORATORY EXAMINATION, WAS FOUND TO BE A POLYACRYLAMIDE. THIS IS A MANMADE SYNITHETIC POLYMER THAT IS USED AS AN AGRICULTURAL SOIL AMENDMENT THAT AIDS IN REDUCING SOIL ERSION. DISTRIBUTION OF THE POLYMER IS TYPICALLY NOT DONE BY AIRCRAFT. INSPECTION OF THE FUELING FACILITY REVEALED THAT THE EMPLOYEES WHO DO REFUELING DID NOT HAVE ANY FORMAL OR ON-THE-JOB TRAINING. THERE WAS NO RECORD THAT THE DELIVERY SYSTEM FILTERS HAD BEEN EXAMINED OR CHANGED. THE MAINTENANCE TO THE TRUCK, DELIVERY SYSTEM, AND STORAGE FACILITY ARE DONE BY THE EMPLOYEES ON AN AS NEEDED, TIME PERMITTED BASIS. THE FUEL TRUCK WAS FOUND TO BE IMPROPERTLY LABELED, AND THE FUEL NOZZLE WAS LYING IN A COMPARTMENT AMID DIRT, GRAVEL, AND OTHER CONTAMINATED WITH NO CAPS OR COVERS FOR PROTECTION.

NTSB investigation

The NTSB’s investigation of this event, with its probable cause and findings. Matched to this report by N-number and date.