CEN09LA145

NTSB accident investigation · Cessna 421C · Wichita, KS · January 30, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
January 30, 2009, 08:10 local (14:10 UTC)
Place
Wichita, KS
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Prior to flight
Aircraft
N345JBCessna 421C
Defining event
Prior to flight: Wrong fuel
Weather
Visual (VMC) · Day
Status
Completed · report May 12, 2009
Report
Approved by Office Director
NTSB office
Central Region
Parties
Cessna Aircraft Company, FAA FSDO
FAA report
20090130001409A
Case key
73289

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 failure of line personnel to ensure that the airplane was serviced with the proper fuel. Contributing to the accident was the Federal Aviation Administration's approval of a Supplemental Type Certificate (STC) which allowed an improper fuel filler opening, and the complacency in non-standard fueling practices by fixed base operator (FBO) line personnel.

Findings · 5

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 · Incorrect service/maintenanceCessna 421C: 3 casesAll aircraft: 1,695 casesProbable cause
Selection/certification/testing: equip certification/testingOrganizational issues › Development · FAA/RegulatorCessna 421C: 1 caseAll aircraft: 21 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid typeCessna 421C: 3 casesAll aircraft: 1,695 casesProbable cause
Personnel issuesPersonnel issues › Task performance · Ground crewCessna 421C: 1 caseAll aircraft: 137 casesProbable cause
Personality/attitude: complacencyPersonnel issues › Psychological · Ground crewCessna 421C: 1 caseAll aircraft: 23 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

During initial climb, the air transport pilot reported a loss of engine power. Unable to return to a runway, the pilot elected to perform a gear-up forced landing to an open field. The twin-engine airplane was substantially damaged during the landing. A line person employed by the fixed base operator (FBO) incorrectly fueled the airplane with 80 gallons of Jet-A instead of 100LL. Two medium single-engine general aviation airplanes based at the FBO had been modified with turbo-prop engines requiring Jet-A fuel. The two modified airplanes were not required by Supplement Type Certificate to modify the fuel filler opening, allowing the airplane to operate with smaller fuel filler openings,which did not comply with certification regulations. Line personnel at the FBO discovered that by rotating the Jet-A nozzle and dispensing at a reduced pressure, Jet-A fuel could be dispensed without using the adapter. Despite having correctly fueled the accident airplane in the past, the line person mistook the accident airplane for one of the converted airplanes and dispensed Jet-A fuel.

Factual narrative

On January 30, 2009, approximately 0810 central standard time, a twin-engine Cessna 421C, N345JB, was substantially damaged during a forced landing following the loss of power on both engines during initial takeoff. The airline transport pilot and the two passengers on board sustained minor injuries during the forced landing. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the Title 14 Code of Federal Regulations Part (CFR) 91 personal flight. The airplane departed Colonel James Jabara Airport (AAO), Wichita, Kansas, at 0808 with the intended destination of Millard Airport (MLE), Omaha, Nebraska. According to the pilot, he landed the previous night with 100 gallons of fuel on board the airplane. The pilot made a request to line personnel to add an additional 40 gallons of fuel to each tank. The morning of the accident, the pilot performed a normal pre-flight, loaded the passengers on the airplane, and taxied for takeoff. The pilot checked the engine instruments, magnetos, and propellers prior to takeoff. During takeoff, the pilot noted 2,800 rpm, 39 inches of manifold pressure, and all engine instruments were "in the green." While climbing to 3,000 feet mean sea level, the airplane's engines began to lose power. The pilot noted propeller rpms were still 2,800 but felt as though no "power" was being produced by the engines; the pilot coordinated for an emergency return. While attempting to troubleshoot the malfunction, the pilot assessed that he could not return to the airport and elected to perform a forced landing. The pilot maneuvered around transmission lines and landed gear up in an open field. The pilot called for emergency services on a cell phone and attended to his passengers. An examination of the airplane revealed that the fuel tanks contained what appeared to be a mixture of 100 low-lead (100LL) and Jet-A fuel. A line person employed by the fixed base operator (FBO), reported to FAA inspectors that he had fueled the accident airplane with 80 gallons of Jet-A. Of note, two Piper PA-46s based at AAO were configured with Pratt & Whitney PT6A turbo-prop engines through a Supplemental Type Certificarte (STC) which does not require a modification of the fuel filler opening. The STC modified airplanes operate with a smaller fuel filler opening than required by Title 14 CFR 23.973. The STC modified airplanes fuel filler openings have placards notifying of the use of Jet-A fuel in accordance with 14 CFR 23.1557. The accident airplane's fuel filler openings were modified in accordance with airworthiness directive 87-21-02 R1 to prevent the "flattened" Jet-A fuel nozzles from entering the fuel filler ports. The placard near the right main fuel tank filler cap was worn and unreadable. The placard near the left main fuel tank filler cap was legible and was in accordance with the FAA approved airplane flight manual. The FBO's Jet-A fuel truck had the "flattened" nozzle, so the line personneldiscovered that the STC modified PA-46s could be refueled without the adapter by rotating the nozzle and dispensing fuel at a reduced pressure. This method became the normal way for the accident line person to refuel the two modified PA-46 airplanes, so the line person reported that he incorrectly thought the accident airplane required Jet-A fuel despite having refueled the accident airplane several times previously.

Aircraft

Registration
N345JB
Reported as
Cessna 421C
Category
Airplane
Serial number
421C0494
Airframe hours
8,034
Engines
GTSIO-520-L, 375 horsepower, reciprocatingContinental GTSIO-520-L, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Fly High Inc
Registered owner
Fly High Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 6, 2008 · 81 hours before
Departed
AAO · Wichita, KS
Destination
MLE · Omaha, NE
Flight plan
IFR
Airport
AAO · Colonel James Jabara Airport

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
61
Injuries
Minor
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 21, 2008
Seat
Left
Flight hours
22,053 total · 49 in this make and model · 15,038 as pilot in command · 84 in the last 90 days · 35 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
30 °F, dew point 16 °F
Altimeter
30.14 inHg
Observed at
AAO, 3 nm away

FAA reports on this event · 1

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