# NTSB ERA09LA130: Cessna 550, N815MA, Wilmington, NC, January 4, 2009

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: January 4, 2009, 02:09 local (07:09 UTC)
- Place: Wilmington, NC
- Coordinates: 34.27639, -77.890556 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.2764&lon=-77.8906&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR missed approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192)
- Highest injury: No injuries
- Injuries: 7 uninjured
- Status: Completed, report December 20, 2010
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO, Cessna Aircraft Company, FAA - AVP100
- NTSB case key (mKey): 73198
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA130
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73198/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73198
- Page: https://openairdocs.org/ntsb/ERA09LA130

## Probable cause

A loss of engine power due to the crew's inadequate in-flight fuel monitoring.

## Findings

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

- [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2076604), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot; cases with it: [Cessna 550, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2076604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=2076604), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md)

## Sequence of events

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

- [Approach-IFR missed approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=2076604), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md)
- [Approach-IFR missed approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 550, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2076604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Landing gear not configured](https://openairdocs.org/ntsb-events/095); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=2076604), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md)
- [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=2076604), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md)

## Analysis

During a night, northbound, international overwater flight that paralleled the east coast of the southeast United States, the airplane encountered headwinds. Upon arrival at the intended destination, the weather was below forecasted conditions, resulting in multiple instrument approach attempts. After the first missed approach, the controller advised the crew that there was an airport 36 miles to the north with "much better" weather, but the crew declined, citing a need to clear customs. During the third missed approach, the left engine lost power, and while the airplane was being vectored for a fourth approach, the right engine lost power. Utilizing the global positioning system, the captain pointed the airplane toward the intersection of the airport's two runways. Approximately 50 feet above the ground, he saw runway lights, and landed. The captain attempted to lower the landing gear prior to the landing, but it would not extend due to a lack of hydraulic pressure from the loss of engine power, and the alternate gear extension would not have been completed in time. The gear up landing resulted in damage to the underside of the fuselage and punctures of the pressure vessel. The captain stated that the airplane arrived in the vicinity of the destination with about 1,000 pounds of fuel onboard or 55 minutes of fuel remaining. However, air traffic and cockpit voice recordings revealed that the right engine lost power about 14 minutes after arrival, and the left engine, about 20 minutes after arrival. Federal air regulations require, for an instrument flight rules flight plan, that an airplane carry enough fuel to complete the flight to the first airport of landing, fly from that airport to an alternate, and fly after that for 45 minutes at normal cruising speed. The loss of engine power was due to fuel exhaustion, with no preaccident mechanical anomalies noted to the airplane.

## Factual narrative

HISTORY OF FLIGHT On January 4, 2009, at 0209 eastern standard time, a Cessna 550, N815MA, was substantially damaged when it impacted a runway during a forced landing with the landing gear retracted at Wilmington International Airport (KILM), Wilmington, North Carolina. The airplane departed La Isabela Airport (MDJB), Santa Domingo, Dominican Republic, on January 3, 2009, about 2220. The certificated airline transport pilot captain, certificated commercial pilot first officer, and five passengers were not injured. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time of the accident and an instrument flight rules (IFR) flight plan was filed for the international flight. The captain reported that there were 5,008 pounds of fuel on board for the 1,090 nautical mile (straight line) flight and that they had planned to depart earlier; however, they were waiting for passengers. During an interview with the Federal Aviation Administration (FAA) inspector on scene, as well as one with an NTSB investigator, the captain stated that the airplane "ran out of fuel." The crew had attempted three instrument landing system (ILS) approaches to runway 24; however, due to fog at the airport, the crew was unable to see the runway environment. On the third missed approach, the No. 1 engine shut down and the pilots requested a vector from air traffic control (ATC) for a fourth approach. The first officer then stated to ATC that they were low on fuel. While being vectored for the fourth approach, the No. 2 engine shut down and the crew requested an immediate turn to the airport. Utilizing the airplane's global positioning system, they were able to locate the center of the airport and "aimed the airplane at the intersection of the runways." Approximately 50 feet above ground level (agl), the captain saw a row of lights, paralleled the lights, landed gear up heading southwest near taxiway G, which intersected runway 6/24. The airplane subsequently overran the runway and impacted several approach light stands for runway 24, coming to rest 2,242 feet past the point of the initial touchdown. In a written statement, the captain also noted that he had tried to lower the landing gear prior to the landing; however, the airplane was "too low," and the landing gear would not extend without engine power. PERSONNEL INFORMATION The captain held an airline transport pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and a type rating in the accident airplane make and model. He reported 6,914 total hours of flight experience, including 5,986 hours as pilot in command (PIC). He reported 1,400 total hours of flight experience in the accident airplane make and model, including 914 hours as PIC. The captain did not report the date of his most recent flight review. His most recent FAA first class medical certificate was issued on May 3, 2007. The firstofficer held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He reported 1,716.6 total hours of flight experience, including 1,137.1 total hours of flight experience in multiengine airplanes. His most recent flight review was completed on November 24, 2007 and his most recent FAA first class medical certificate was issued on March 6, 2008. AIRCRAFT INFORMATION The accident airplane was manufactured in 1982, and was issued an airworthiness certificate on May 20, 1982. The airplane was powered by two Pratt and Whitney JT15D-4 Series turbofan engines. According to the captain, the airplane was last inspected utilizing a conditional airworthiness inspection on September 10, 2008, and at that time, the airplane had accrued 11,123 total hours of service. METEOROLOGICAL INFORMATION The 0153 recorded weather observation at KILM included winds from 020 degrees at 3 knots, a broken cloud layer at 100 feet agl, an overcast cloud layer at 500 feet agl, 1/2 statute mile (sm) visibility in fog, temperature 11 degrees C, dew point 10 degrees C, and an altimeter setting of 30.14 inches of mercury. In a completed NTSB Pilot/Operator Report, the captain indicated that he had received a weather briefing via telephone/computer. In a written statement, the captain noted that the weather forecast for KILM "for this flight was 800 to 900 overcast and 3 sm visibility." According to the 032339Z TAF (Terminal Area Forecast), KILM weather for the arrival time was expected to include calm winds, visibility in excess of 6 sm, and a broken cloud layer at 700 feet. During a telephone interview, the captain reported that the airplane had encountered "severe headwinds" en route to KILM. COMMUNICATION According to FAA partial transcripts of radio communications, the crew initially contacted Miami Air Route Traffic Control Center (ARTCC) at 2233, and reported to be level at flight level 280. At 0022, the flight was cleared to descend to flight level 270. At 0050, the flight was cleared to contact Jacksonville ARTCC, which was complied with. At 0121, the controller issued a pilot's discretionary descent to 5,000 feet above mean sea level (msl). At 0133, the crew was told to contact Washington ARTCC. The crew made initial contact with Washington ARTCC at 0134, and reported descending to 5,000 feet msl. The controller informed the crew of the weather for KILM and confirmed that they wanted vectors for the ILS runway 24 approach. At 0147, the controller cleared the flight for the approach. At 0150, the first officer informed the controller that they were on the missed approach and would like to "shoot another approach." At 0152, the controller informed the crew that, at an airport 36 miles to the north of KILM, the "weather is much better." The first officer informed the controller that they had to clear customs at KILM. At 0155, the controller again cleared the airplane for the ILS runway 24 approach.At 0157, the first officer requested "another approach." At 0201, the controller cleared the airplane for another ILS runway 24 approach. At 0204:30, the first officer informed the controller, "…we have an emergency one engine out." At 0204:34, the controller asked, "can you make it to albert ellis," and the first officer responded, "how far can you give me a vector right away." The controller then stated, "ah fly heading of ah zero one zero," which the first officer acknowledged. At 0204:45, the controller stated, "roger it's thirty six miles north of Wilmington," and the first officer responded, "ah we can not do this we are we have low fuel." At 0205:38, the first officer stated, "we [have] low fuel we got [low] fuel." The controller then vectored the airplane toward runway 35. The last radio transmission from the first officer was at 0209:33, when he responded, "mike" to the controller stating that the airplane was directly over the airport. At 0210:30, the controller advised, "november eight one mike five mike alpha radar contact lost." According to the cockpit voice recorder transcript, at 0149, the first officer advised the controller of the missed approach; at 0203, the captain stated to the first officer, "we just lost an engine;" and at 0209, there were sounds consistent with the loss of power from the second engine. AIRPORT INFORMATION The airport air traffic control tower hours of operation were from 0600 to 2300 local time and it was closed at the time of the accident flight's arrival. The airport also had two crossing runways. The longest runway was 6/24, which was 8,016 feet long and 150 feet wide. The crossing runway was 17/35, which was 7,004 feet long and 150 feet wide. Runway 6/24 was equipped with pilot-activated approach and runway lights. The airport was served by three ILS approaches. FLIGHT RECORDERS The cockpit voice recorder was auditioned and transcribed. The information heard was consistent with the information that the pilots reported to NTSB investigators both in a telephone interview and in writing. WRECKAGE AND IMPACT INFORMATION The airplane was examined by an FAA inspector who responded to the accident site. The airplane sustained skin damage to the underside of the fuselage and several puncture holes into the pressure vessel. No other damage was noted. ADDITIONAL INFORMATION The Cessna Citation Operators Manual, Section VII, "Performance – Flight Planning" charts, revealed that at flight level (FL) 290 with a 25-knot headwind condition, the flight would be able to travel 1,302 nautical miles (nm). At FL270, the flight would be able to travel 1,239 nm. The distances included utilizing all fuel on board and flying at a specific climb and cruise profile; however, they do not take into consideration the amount of distance and time to complete an instrument approach. The actual flight profile flown was not determined. Federal Air Regulation 91.167, Fuel Requirements for Flight in IFR Conditions, states, in part,"(a) No person may operate a civil aircraft in IFR conditions unless it carries enough fuel (considering weather reports and forecasts and weather conditions) to – (1) Complete the flight to the first airport of landing; (2) Fly from that airport to the alternate airport; and (3) Fly after that for 45 minutes at normal cruising speed." According to the captain's written statement, the airplane arrived at KILM with "about 1,000 lbs of fuel (00.55 minutes) remaining." The Cessna Citation Operating Manual, Section II, "Airplane and Systems," also noted that the landing gear was electrically controlled and hydraulically operated, and that there was an emergency extension system that could be actuated by a red AUX GEAR CONTROL T-handle located under the pilot's instrument panel.

## Aircraft

- Registration: [N815MA](https://openairdocs.org/deregistered/N815MA-2010-05-05), registration cancelled 2010-05-05, S/N 5500406, built 1987 (OpenAirDocs)
- Reported make and model: CESSNA 550
- Registry model: [Cessna 550](https://openairdocs.org/model/cessna-550) (registry code 2076604) (OpenAirDocs)
- Registry engine: [Pratt & Whitney Canada JT15D-4 series](https://openairdocs.org/engine/pratt-whitney-canada-jt15d-4-series) (registry code 52112, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 5500406
- Airframe hours: 11123
- Engines: Pratt and Whitnety Canada JT15D-4 2500 lbs thrust turbo fan; Pratt and Whitnety Canada JT15D-4 2500 lbs thrust turbo fan
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Caribair SA
- Registered owner: Joda LLC
- Airworthiness certificate: Standard, Transport
- Last inspection: Condition, September 10, 2008
- Departed: MDJB, Santa Domingo
- Destination: KILM, Wilmington, NC
- Flight plan: IFR
- Airport: KILM, Wilmington International Airpo, runway 06, 8,016 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 38; injuries: none; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review February 18, 2007; seat: left; flight hours: 6,914 total, 1,400 in this make and model, 5,986 as pilot in command, 147 in the last 90 days, 49 in the last 30 days, 7 in the last 24 hours
- Co-pilot; age 28; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 24, 2007; seat: right; flight hours: 1,717 total, 1,454 as pilot in command, 82 in the last 90 days, 19 in the last 30 days

## Weather

- Conditions: Instrument (IMC), Night
- Wind: 20° at 3 knots
- Visibility: 0.5 statute miles
- Lowest ceiling: 100 ft broken
- Temperature: 52 °F, dew point 50 °F
- Altimeter: 30.13 inHg
- Observed at: KILM

## Docket (19 files)

The files NTSB released with the investigation on August 19, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73198.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 620 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313876&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Phone Interview with Captain (item 2, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325924&FileExtension=.PDF&FileName=Phone%20Interview%20with%20Captain-Master.PDF
- Captain Written Statement (item 3, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325929&FileExtension=.PDF&FileName=Captain%20Written%20Statement-Redacted.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (First Officer) (item 4, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325925&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(First%20Officer)-Redacted.PDF
- Written Statement From First Officer (item 5, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325930&FileExtension=.PDF&FileName=Written%20Statement%20From%20First%20Officer-Redacted.PDF
- Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 6, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326861&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Passengers Written Statements (item 7, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325931&FileExtension=.PDF&FileName=Passengers%20Written%20Statements-Redacted.PDF
- Commercial Representation of Basic Flight Track (item 8, .PDF, 872 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335149&FileExtension=.PDF&FileName=Commercial%20Representation%20of%20Basic%20Flight%20Track%20-Master.PDF
- ATC Transcript Miami and Jacksonville Center (Partial) (item 9, .PDF, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325934&FileExtension=.PDF&FileName=ATC%20Transcript%20Miami%20and%20Jacksonville%20Center%20(Partial)-Redacted.PDF
- ATC Transcript Washington Center (Partial) (item 10, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325935&FileExtension=.PDF&FileName=ATC%20Transcript%20Washington%20Center%20(Partial)-Redacted.PDF
- ATC Audio and Radar Data (item 11, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326045&FileExtension=.PDF&FileName=ATC%20Audio%20and%20Radar%20Data-Master.PDF
- Excerpts, Cessna Citation Operating Manual (item 12, .PDF, 830 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335053&FileExtension=.PDF&FileName=Excerpts,%20Cessna%20Citation%20Operating%20Manual-Master.PDF
- Additional Excerpt, Cessna Citation Operating Manual (item 13, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335146&FileExtension=.PDF&FileName=Additional%20Excerpt,%20Cessna%20Citation%20Operating%20Manual-Master.PDF
- Maps or Charts of Accident Area, Wreckage Diagrams (Courtesy of Wilmington Fire Department) (item 14, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325922&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams%20(Courtesy%20of%20Wilmington%20Fire%20Department)-Master.PDF
- Wimington Weather (item 15, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326026&FileExtension=.PDF&FileName=Wimington%20Weather-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 16, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326081&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 17, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313877&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Photo 1: Airplane At Rest (Courtesy of FAA) (item 18, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325926&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20At%20Rest%20(Courtesy%20of%20FAA)-Master.PDF
- Photo 2: Airplane At Rest Left Side (Courtesy of Wilmington Fire Department) (item 19, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325940&FileExtension=.PDF&FileName=Photo%202%3A%20Airplane%20At%20Rest%20Left%20Side%20(Courtesy%20of%20Wilmington%20Fire%20Department)-Master.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.

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