# NTSB CEN22LA190: Cessna 421, Houston, TX, May 6, 2022 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: May 6, 2022, 14:18 local (19:18 UTC) - Place: Houston, TX - Coordinates: 29.609208, -95.2648 - Nearby events: https://openairdocs.org/map.md?lat=29.6092&lon=-95.2648&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 4 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA Flight Standards - NTSB case key (mKey): 105048 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA190 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105048/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105048 - Page: https://openairdocs.org/ntsb/CEN22LA190 ## Probable cause The fixed-base operator’s incorrect fueling of the airplane, which resulted in a total loss of power in both engines. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Airport personnel (probable cause); cases with it: [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid type (probable cause); cases with it: [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: CESSNA 421 (C) - Category: Airplane - Serial number: 421C-0085 - Year built: 1976 - Airframe hours: 5197 - Engines: Continental GTSIO-520-L 375 horsepower reciprocating; Continental 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. - Pilot; age 60; injuries: minor; 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 files) The files NTSB released with the investigation on August 15, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105048. 38.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 24.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13870367&FileExtension=pdf&FileName=Accident%20Report%20--%20CEN22LA190_redacted-Rel.pdf - Accident photos (item 2, PDF, 8 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13871424&FileExtension=pdf&FileName=Accident%20Photos%20--%20CEN22LA190-Rel.pdf - Statements -- fixed base operator (item 3, PDF, 4 pages, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14343593&FileExtension=pdf&FileName=FBO%20Statements%20--%20CEN22LA190_redacted-Rel.pdf - Airplane fueling documentation -- fixed base operator (item 4, PDF, 5 pages, 11.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14354120&FileExtension=pdf&FileName=Fueling%20Documentation%20--%20XB-FQS_Redacted-Rel.pdf 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.