# NTSB CEN09LA095: Cessna 402, N4504B, Madison, WI, December 17, 2008

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: December 16, 2008, 22:52 local (Dec 17, 2008, 04:52 UTC)
- Place: Madison, WI
- Coordinates: 43.13972, -89.337501 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.1397&lon=-89.3375&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR final approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report April 12, 2011
- Report: Approved by Office Director
- NTSB office: Central Region
- NTSB case key (mKey): 69581
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA095
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69581/pdf
- Page: https://openairdocs.org/ntsb/CEN09LA095

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 402B, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=207590P), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 402B, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=207590P), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-holding (IFR): Air traffic event](https://openairdocs.org/ntsb-events/100); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-events/100/sequence.md?model=207590P), [All aircraft, 115 cases](https://openairdocs.org/ntsb-events/100/sequence.md)
- [Enroute: Structural icing](https://openairdocs.org/ntsb-events/210); cases with it: [Cessna 402B, 2 cases](https://openairdocs.org/ntsb-events/210/sequence.md?model=207590P), [All aircraft, 102 cases](https://openairdocs.org/ntsb-events/210/sequence.md)
- [Approach-IFR final approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 402B, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=207590P), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md)

## 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](https://openairdocs.org/deregistered/N4504B-2017-06-30), registration cancelled 2017-06-30, S/N 402B1370, built 1978 (OpenAirDocs)
- Reported make and model: CESSNA 402 (B)
- Registry model: [Cessna 402B](https://openairdocs.org/model/cessna-402b) (registry code 207590P) (OpenAirDocs)
- Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 402B1370
- Airframe hours: 12805
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 30; injuries: none; 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 (OpenAirDocs).

- [Accident 20081217857419A](https://openairdocs.org/incident/20081217857419A), Dec 17, 2008: Cessna 402B, Madison, WI, Destroyed. Aircraft departed atw at 0234Z. Aircraft arrived at bjb at 0300Z. Aircraft on downwind leg at mke at 0318Z. At 0318Z ATC instructs aircraft to turn and hold at…

## Other investigations on N4504B (1)

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

- [NTSB BFO93LA164](https://openairdocs.org/ntsb/BFO93LA164), Sep 8, 1993: Cessna 402B (N4504B), Eau Claire, PA, substantial damage. Probable cause: The separation of the number four cylinder on the airplane's left engine for undetermined reasons. A factor in the accident was the rough/uneven terrain.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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