ANC94LA091

NTSB accident investigation · Cessna T207A · Haines, AK · July 21, 1994

Accident · No injuriesLimited investigationFinal report
Date
July 21, 1994, 15:45 local (23:45 UTC)
Place
Haines, AK
Injuries
7 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
CFHOICessna T207A
Weather
Visual (VMC) · Day
Status
Completed · report January 26, 1995
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Case key
2528

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Fuel starvation as a result of the pilot's improper in-flight planning/decision and his failure to follow the procedures contained in the airplane checklist for engine failure.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalClimb
Fluid,fuel - starvationCause
Procedures/directives - improperPilot in commandCause
Checklist - not followedPilot in commandCause
Forced landingDescent - emergency
In flight collision with terrain/waterDescent - emergency

Analysis

The pilot of a sightseeing flight reportedly departed the airport with the right fuel tank selected and one hour of fuel endurance in the tank. Approximately 45 minutes later, the engine lost power without warning. The pilot switched to the left fuel tank but did not use the fuel boost pump as directed by the airplane checklist. No problems were found with the engine during post accident inspections performed by licensed mechanics.

Factual narrative

History of flight

On July 21, 1994, at 1545 Alaska daylight time, a wheel equipped Cessna T207A airplane, Canadian registry C-FHOI, operated by Summit Air Charters LTD. of Atlin, British Columbia (BC), collided with terrain following a loss of engine power over the Meade Glacier. The accident site is approximately 50 miles southwest of Atlin and about 12 km inside U.S. territory. The Canadian certificated commercial pilot and his six passengers were not injured and the airplane sustained substantial damage. The commercial charter flight, operating under Class 4 and Class 94 Canadian authorization, last departed Atlin at 1502 on a VFR flight plan with the White Horse Flight Service Station (FSS) for the purpose of sight seeing the Meade Glacier. The sightseeing flight was scheduled to last approximately one hour. VFR conditions prevailed in the area at the time of the mishap.

On July 25, 1994, the Transportation Safety Board of Canada delegated the accident investigation to the U.S. National Transportation Safety Board, Northwest Field Office, Anchorage, Alaska.

Flightcrew information

Mr. Fayez R. Cassis, date of birth November 29, 1968, is the holder of Canadian Commercial Pilot Certificate No. C368304 with the ratings and limitation of airplane single and multi-engine land, group 1 instrument rating. He was issued a Class 1 medical certificate on December 1, 1993 with no limitations. He completed ground and flight training on the Cessna 207 aircraft with Summit Aviation in April 1994. At the time of the accident, he had accrued a total of 48 flight hours in the non aspirated Cessna 207, of which 45 were as pilot-in-command.

On the morning of July 29, 1994, the NTSB investigator-in- charge conducted a telephone interview with Mr. Cassis. Mr. Cassis said that he believed that the accident flight was his first in a Cessna Turbo (T) 207 aircraft. He said that the hourly fuel burn in the generic 207 was about 60 liters per hour (15.7 U.S. gal p/hr) and in the T207 about 84 liters per hour (22.2 U.S. gal p/hr). He performed a preflight and runup check on the airplane prior to departing Atlin. This included dip sticking the fuel tanks for quantity and draining the fuel sumps. The flight departed Atlin with the engine being fed from the right wing main fuel tank. The total fuel endurance on board the airplane was two hours and forty minutes. The distribution of fuel was 1 hour and forty minutes of fuel in the left main tank and one hour of fuel in the right main tank. The flight had been in progress for about 45 minutes when the engine began to sputter then quit without warning. There were no metallic sounds and/or abnormal engine pressure/temperature indications associated with the loss of power. At the time, the plane was in a climbing attitude about 800 feet above the glacier. He recalled seeing a drop in the engine fuel pressure indication as the engine began to loose power. He switch to the left main fuel tank, but did not use the engine fuel boost pump. He performed an emergency landing on the glacier about one minute after the engine quit.

No toxicological testing was performed on the pilot.

Witness/other persons

On the morning of July 28, 1994, the NTSB investigator-in- charge conducted the first of several telephone interview with Mr. Jamie Tate. Mr. Tate is the owner of Summit Aviation. He is a Canadian licensed commercial pilot, and he also possesses a Canadian airplane maintenance engineer license. On July 22, 1994, Mr. Tate and Mr. Barry Mortinsen, a U.S. licensed airplane mechanic, helicoptered to the accident site to inspect and recover the airplane. The accident site was characterized as rough and uneven glaciated terrain. The plane was resting on its main landing gear and the lower engine cowling. The nose and aft portion of the fuselage sustained the majority of the airframe damage. The three propeller blades were bent backwards to a similar degree. Both wings were attached to the fuselage and showed no signs of damage. The wings were facing a downhill slope to the right of about 20 degrees. The left wing fuel tank was empty and the right wing fuel tank was estimated to have contained about five gallons of fuel. The passenger seating area did not appear to have sustained any notable damage. The nose gear assembly was bent rearward and compressed the belly of the airplane in the area of the fuel selector manifold. The fuel selector was found jammed between the off and left tank positions. The fuel system lines were ruptured in the belly of the airplane below the fuel selector. Aviation fuel stained the ground in this area. The engine fuel screens were clear and there was fuel in the fuel bowl up to the fuel pump and fuel control distributor. No evidence of fuel was found in the fuel spider lines. Aside from the bottom of the engine oil pan, there was no physical evidence of external damage to the engine assembly. The engine oil screen was clean. The magneto "P" ground leads were secure, and the magneto's produced a good hand spark. The spark plugs showed normal wear. The engine turned over by hand without difficutly. Mr. Tate said that the airplane burned, on average, approximately 80 liters of fuel per hour. Mr. Tate said his company had flown the airplane about 100 hours since initially leasing it and that they had not experienced any problems with the airplane.

Aircraft information

Cessna T207A, SN:20700581, Registration C-FHOI, was manufactured in 1980. The airplane is equipped with long range fuel tanks having a total capacity of 40 gallons each with 73 gallons useable. According to the engine and airframe records, the airplane was maintained by Summit Aviation under Cessna Aircraft Corporations progressive maintenance inspection program. The last recorded entry in the engine maintenance log was June 14, 1994, for a 200 hour inspection. As of that date, the total time on the engine since overhaul was 105.7 hours. The record of maintenance performed on this date included removal and replacement of the No. 3 cylinder due to a crack at a spark plug hole, and the removal and replacement of the No. 2 cylinder and piston as a result of a cracked intake part. Recorded entries in the airframe log book for June 14, 1994, included essentially the same information as the engine log. The total tack time on the airframe as of June 14, 1994, was 6259.2 hours. The last recorded entry in the airframe log was June 15, 1994 for ELT recertification. The airplane's journey log showed an entry for a 50 hour inspection at a tack time of 6310.4 hours. The tack time on the airplane at the accident site was 6353.8 hours.

The emergency procedures section of the normally aspirated and Turbo Cessna 207 Pilot Operating Handbook's stipulate that the following procedures are applicable for Engine Failure During Flight: 1, Airspeed -- 80 KIAS. 2. Fuel Selector Valve and Quantity -- Check. 3. Auxiliary Fuel Pump -- ON for 3-5 seconds with throttle 1/2 open; then OFF. 4. Ignition Switch -- BOTH (or START if propeller is stopped). 5. Throttle -- ADVANCE slowly.

The total unusable fuel (both standard and long range tanks) in the Cessna 207 is 7 gallons.

Aircraft

Registration
CFHOI
Reported as
Cessna T207A
Category
Airplane
Serial number
20700581
Engine
Continental TSIO-520-M, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 91
Operator
Summit Air Charters Ltd.
Registered owner
Ostashek, John
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · June 15, 1994
Departed
Atlin, Bc
Flight plan
Company VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
25
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
436 total · 48 in this make and model · 196 as pilot in command · 45 in the last 90 days · 15 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
225° at 5 knots
Visibility
6 statute miles
Lowest ceiling
None
Temperature
16 °F