CEN22LA190

NTSB accident investigation · Cessna 421 · Houston, TX · May 6, 2022

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
May 6, 2022, 14:18 local (19:18 UTC)
Place
Houston, TX
Injuries
4 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
XB-FQSCessna 421
Defining event
Initial climb: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA Flight Standards
Case key
105048

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

On this page

Probable cause

The fixed-base operator’s incorrect fueling of the airplane, which resulted in a total loss of power in both engines.

Findings · 3

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.

Action: incorrect action performancePersonnel issues › Action/decision · Airport personnelAll aircraft: 1,386 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid typeAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Incorrect service/maintenanceAll 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 pilot reported that, before the flight, the airplane was fueled with 140 gallons of Jet A fuel. Shortly after takeoff, both engines lost total power. Because the airplane had insufficient altitude to return to the airport, the pilot executed a forced landing to a field and the left wing sustained substantial damage. A postcrash fire ensued. The investigation determined that the airplane was inadvertently fueled with Jet A fuel rather than AVGAS, which was required for the airplane’s reciprocating engines. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports; however, postaccident examination of the airplane found that a decal specifying AVGAS was present at the right-wing fuel port. The investigation could not determine whether the same or a similar decal was present at the left-wing fuel port because the left wing was partially consumed during the postimpact fire.)

Factual narrative

On May 6, 2022, at 1418 central daylight time, a Cessna 421 airplane, Mexican registration XB-FQS, was substantially damaged when it was involved in an accident near Houston, Texas. The pilot and three passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, upon arriving at the airport’s fixed-base operator (FBO) facility, his son requested that the airplane be fueled with 70 gallons in each wing tank. They observed the airplane being fueled; several minutes later, the airplane was towed to their location at the FBO building. The pilot stated that the preflight inspection and taxi for takeoff were completed with no issues found. About halfway through the takeoff roll, the pilot thought that the airplane was “feeling weird” but was unable to stop on the remaining runway. The pilot continued with the takeoff; shortly afterward, the engines began losing power and the airplane had insufficient altitude to return to the airport. The pilot decided to execute a forced landing to a field ahead of the airplane’s flightpath. During the forced landing, the landing gear collapsed and the airplane impacted a perimeter fence. The left wing separated outboard of the engine nacelle and the airplane came to rest in a residential backyard. A postimpact fire consumed the outboard portion of the left wing. A representative of the FBO stated the pilot’s son placed the order for fuel with a front counter customer service representative. The order was noted as “70 neg each” and confirmed with the pilot’s son. The order relayed to line service was for “70 gallons each wing – negative,” indicating that a fuel additive (Prist) should not be added. The type of fuel was not discussed. The airplane was subsequently fueled with 140 total gallons of Jet A fuel without the Prist additive. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports and that, for that reason, he confirmed the order with the front desk before adding Jet A fuel to the airplane. The airplane was powered by two reciprocating engines requiring 100/100 low-lead minimum-grade aviation fuel (AVGAS). A postaccident examination by Federal Aviation Administration inspectors found that the right-wing fuel port had decals noting “100/130 Aviation Grade Min” and “AVGAS ONLY.” The decal text was faded but was clearly visible. The investigation could not determine if there were any left-wing fuel port decals because of the fire damage to the left wing. In addition, the truck used to fuel the airplane had a placard indicating “Jet A,” and an elongated fuel nozzle was installed, corresponding with Jet A fueling operations. After the accident, the FBO implemented additional communication requirements and awareness training related to aircraft fueling to prevent an incorrect fueling event from occurring.

Aircraft

Registration
XB-FQS
Reported as
Cessna 421 (C)
Category
Airplane
Serial number
421C-0085
Built
1976
Airframe hours
5,197
Engines
Continental GTSIO-520-L, 375 horsepower, reciprocatingContinental GTSIO-520-L, 375 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 3, 2021 · 38 hours before
Departed
HOU · Houston, TX
Destination
SAT · San Antonio, TX
Flight plan
VFR
Airport
HOU · William P Hobby, runway 13R, 7,602 × 150 ft, asphalt
Equipment
Stall warning system, Electronic primary flight display, ADS-B

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
November 15, 2021
Seat
Left
Restraint
3-point
Flight hours
4,025 total · 951 in this make and model · 3,974 as pilot in command · 30 in the last 90 days · 10 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 9 knots
Visibility
10 statute miles
Temperature
88 °F, dew point 73 °F
Altimeter
29.87 inHg
Observed at
KHOU, 2 nm away
METAR
METAR KHOU 061853Z 11009KT 10SM SCT032 31/23 A2987

Docket · 4

The files NTSB released with the investigation on August 15, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 38.1 MB in all.