# NTSB CEN09LA145: Cessna 421C, N345JB, Wichita, KS, January 30, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: January 30, 2009, 08:10 local (14:10 UTC) - Place: Wichita, KS - Coordinates: 37.769138, -97.209945 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.7691&lon=-97.2099&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Wrong fuel](https://openairdocs.org/ntsb-events/194) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed, report May 12, 2009 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Cessna Aircraft Company, FAA FSDO - ADs cited in the narratives: [AD 87-21-02 R1](https://openairdocs.org/ad/87-21-02-R1) (OpenAirDocs) - NTSB case key (mKey): 73289 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA145 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73289/pdf - Page: https://openairdocs.org/ntsb/CEN09LA145 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Cessna 421C, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2076016), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Selection/certification/testing: equip certification/testing](https://openairdocs.org/ntsb-findings/04012015): Organizational issues › Development · FAA/Regulator (probable cause); cases with it: [Cessna 421C, 1 case](https://openairdocs.org/ntsb-findings/04012015/cases.md?model=2076016), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/04012015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid type (probable cause); cases with it: [Cessna 421C, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2076016), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Ground crew (probable cause); cases with it: [Cessna 421C, 1 case](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=2076016), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/cases.md) - [Personality/attitude: complacency](https://openairdocs.org/ntsb-findings/02021020): Personnel issues › Psychological · Ground crew (probable cause); cases with it: [Cessna 421C, 1 case](https://openairdocs.org/ntsb-findings/02021020/cases.md?model=2076016), [All aircraft, 23 cases](https://openairdocs.org/ntsb-findings/02021020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Wrong fuel](https://openairdocs.org/ntsb-events/194) (defining event); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-events/194/sequence.md?model=2076016), [All aircraft, 9 cases](https://openairdocs.org/ntsb-events/194/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 421C, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2076016), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2076016), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N345JB-2009-12-14), registration cancelled 2009-12-14, S/N 421C0494 (OpenAirDocs) - Reported make and model: CESSNA 421C - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Category: Airplane - Serial number: 421C0494 - Airframe hours: 8034 - Engines: GTSIO-520-L 375 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; 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 (OpenAirDocs). - [Accident 20090130001409A](https://openairdocs.org/incident/20090130001409A), Jan 30, 2009: Cessna 421C, Benton, KS, Substantial damage. (-23) On January 30, 2009, at approximately 0810, shortly after departure from jabara airport (aao), while climbing through 3000 feet, Cessna 421C, N345JB,… 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.