CEN09LA095

NTSB accident investigation · Cessna 402 · Madison, WI · December 17, 2008

Accident · No injuriesLimited investigationFinal report
Date
December 16, 2008, 22:52 local (Dec 17, 2008, 04:52 UTC)
Place
Madison, WI
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N4504BCessna 402
Defining event
Approach-IFR final approach: Fuel exhaustion
Weather
Instrument (IMC) · Night
Status
Completed · report April 12, 2011
Report
Approved by Office Director
NTSB office
Central Region
FAA report
20081217857419A
Case key
69581

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

The pilot’s improper fuel management, which resulted in a loss of engine power during an instrument landing due to fuel exhaustion.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 402B: 4 casesAll aircraft: 1,695 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The on-demand cargo flight departed for the destination airport and was delayed en route due to repetitive destination airport closures. The closures were the result of snow-contaminated runways. The pilot then diverted to an alternate airport due to concerns about remaining fuel reserves. The airplane experienced a loss of engine power during an instrument approach at the alternate airport and impacted the ground about 200 yards short of the landing runway. A postaccident inspection of the airplane revealed no usable fuel on board.

Factual narrative

On December 16, 2008, at 2252 central standard time, a Cessna 402B, N4504B, operated by Freight Runners Express, Inc., received substantial damage on impact with terrain during a forced landing near Madison, Wisconsin. The commercial pilot was uninjured. The 14 CFR Part 135 on-demand cargo flight was operating on an instrument flight rules flight plan. The flight originated from Appleton, Wisconsin, at 2030 and was en route to Milwaukee, Wisconsin. In preparation for an on-demand cargo flight, the pilot reportedly obtained preflight information at 1935 indicating General Mitchell International Airport (MKE), Milwaukee, Wisconsin, was closed but was to reopen at 2015. The pilot was informed during taxi for departure that there would be a 10 minute departure delay. After the delay, the airplane departed and the pilot reduced cruise speed by about 10 knots due to "backed up" traffic at MKE. While en route, air traffic control (ATC) informed the pilot that MKE reopened. The pilot received radar vectors that took the airplane over Lake Michigan and then to the west for the ILS 7R approach. When the airplane reached a midfield downwind position during the approach, MKE closed again due to a poor braking action report. The airplane was then vectored to a holding fix where the pilot completed 1 1/2 turns before receiving radar vectors for ILS 7R. The airplane flew the ILS 7R approach, was on a 2 mile final, and cleared to land, when the pilot was instructed by ATC to perform a missed approach. A poor braking action report was reported and MKE closed again. The pilot contacted the operator who told the pilot to divert to Chicago/Rockford International Airport (RFD), Rockford, Illinois. The pilot asked ATC for minimal vectors to RFD and did not use the specific verbiage, "minimum fuel." He noticed that the airplane's indicated airspeed began to decrease 15-20 knots with an accumulation of ice on the wings, which he described as severe. He decided that he would not be able to divert to RFD due to fuel and diverted to Dane County Regional Airport-Truax Field (MSN), Madison, Wisconsin, since it was closer. He executed a climb to 8,000 feet to get out of the icing. He requested and received clearance for the ILS 36 approach at MSN. The left engine began to sputter as the airplane neared the approach's decision height. The pilot shut the engine down and thereafter was unable to maintain altitude. The airplane impacted terrain approximately 200 yards short of runway 36. Post accident inspection of the airplane revealed no usable fuel in the airplane's fuel tanks.

Aircraft

Registration
N4504B
Reported as
Cessna 402 (B)
Category
Airplane
Serial number
402B1370
Airframe hours
12,805
Engine
Teledyne Continental Motors TSIO-520-E, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Freight Runners Express, Inc.
Registered owner
Freight Runners Express, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 14, 2008 · 12,805 hours before
Departed
ATW · Appleton, WI
Destination
MKE · Milwaukee, WI
Flight plan
IFR
Airport
MSN · Dane County Regional Airport, runway 36, 9,006 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
November 3, 2008
Flight hours
2,069 total · 274 in this make and model · 1,519 as pilot in command · 92 in the last 90 days · 30 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
360° at 3 knots
Visibility
1 statute miles
Lowest ceiling
1,000 ft broken
Temperature
9 °F, dew point 5 °F
Altimeter
30.07 inHg
Observed at
MSN

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N4504B · 1

Matched to the same aircraft by N-number and date.