ERA11LA405

NTSB accident investigation · Cessna U206G · Matinicus Island, ME · July 17, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
July 17, 2011, 16:25 local (20:25 UTC)
Place
Matinicus Island, ME
Injuries
1 serious, 3 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N910TACessna U206G
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report November 7, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors Inc, Cessna Aircraft Company, FAA/FSDO
FAA report
20110717021649A
Case key
81132

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 pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation.

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.

Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna U206G: 2 casesAll aircraft: 719 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationCessna U206G: 1 caseAll aircraft: 176 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna U206G: 2 casesAll 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

After takeoff from the island airport for the air taxi flight, the pilot made the initial power reduction when the airplane was at an estimated 200 feet above the ocean. At that time, the engine lost total power, and the pilot ditched the airplane. The pilot and the three passengers were able to exit the airplane before it sank. For about 1 hour until rescuers reached them, they held onto a section of the airplane’s belly cargo pod that had separated during the water impact. At the time of the wreckage recovery, the left and right fuel tank filler caps were found securely installed. The fuel selector was found in the right fuel tank position. About 25 gallons of sea water and 1 pint of aviation fuel were drained from the right fuel tank. About 27 gallons of aviation fuel and 2 gallons of sea water were drained from the left tank. Examination of the wreckage did not reveal any discrepancies that would have prevented normal operation of the airplane. The physical evidence indicates that the engine lost power as a result of fuel starvation due to the position of the fuel selector on the empty right tank. The operator required the pilot to provide the passengers a safety briefing before takeoff. However, none of the passengers were briefed or were aware that life vests were onboard the airplane. If a piece of wreckage had not been available for the passengers to hold on to, the failure of the pilot to notify the passengers of the availability of life vests could have increased the severity of the accident. As a result of the accident, the operator made numerous safety changes including mandating that the pilot read out loud a pre-takeoff briefing referencing the onboard passenger briefing guide card and offering all passengers a personal flotation device to wear during flights.

Factual narrative

On July 17, 2011, about 1625 eastern daylight time, a Cessna U206G, N910TA, registered to and operated by Waters Aero Marine, Inc., doing business as Penobscot Island Air, ditched in the ocean near Matinicus Island Airport (35ME), Matinicus Island, Maine. The pilot and two of three passengers received minor injuries, and the third passenger received serious injuries; the airplane sustained substantial damage. Visual meteorological conditions prevailed, and a company flight plan was filed for the on-demand air taxi flight, conducted under the provisions of 14 Code of Federal Regulations Part 135. The flight originated from 35ME, about 1623, with a destination to Knox County Regional Airport (KRKD), Rockland, Maine. The pilot stated they departed 35ME with good weather with a light wind. The airplane did not show any abnormal indications on the takeoff roll. At approximately 200 feet into the climb, as he was reducing to climb power, the engine began to lose power. He immediately advanced the throttle and turned on the auxiliary fuel pump with no results. The engine lost total power and the pilot ditched the airplane into the ocean. All onboard were able to exit the airplane before it sank. They clung onto a section of the airplane’s belly cargo pod that separated during the water impact. When the flight did not report in on the company’s frequency as required by the operator’s General Operations Manual (GOM), a search and rescue operation was activated. At about 1655 an emergency locater transmitter (ELT) signal was heard. At 1724 the pilot and three passengers were located in the water by a search plane. At 1737 all were rescued by a fishing boat and taken to shore for medical attention. The pilot held an Airline Transport pilot certificate with ratings for airplane multiengine land, airplane single-engine land and sea, and rotorcraft helicopter; with type rating for B-757, B767, and BH-212. In addition, he held a flight instructor certificate with ratings for airplane-single engine and instrument airplane. The pilot reported that he accumulated 25,300 total hours of flight experience, of which, 1,000 hour were in the same make and model as the accident airplane. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on May 24, 2010. The Cessna U206G, a six place all metal, high wing, single-engine airplane, variable-pitch propeller, with fix landing gear, serial number U20604102, was manufactured in 1978, and issued a standard airworthiness certificate, in the normal category. The airplane was powered by a Continental IO-520-F, 300-horsepower engine, with a McCauley three bladed propeller. The airplane was equipped with a belly cargo pod and had extended range fuel tanks, with a capacity for 80 gallons of fuel, which 78 gallons are usable. The airplane’s engine was overhauled on June 29, 2009. The engine’s last inspection was performed on July 7, 2011, at which the engine had a total of 1,244.9 hourssince major overhauled. The airplane’s last inspection was July 7, 2011 and the airplane had a total of 10,434.6 hours at that time. The airplane was on an annual/100 hour maintenance schedule. At the time of the accident, the airplane had accumulated a total of 10,437 hours. The wreckage was recovered 5 days after the accident from an estimated ocean floor depth of 80 feet and taken to a storage facility under FAA oversight. The left and right fuel tank filler caps were secured in their respective place. The fuel selector was observed in the right fuel tank position. Approximately 25 gallons of sea water was drained from the right fuel tank and about a pint of aviation fuel was observed. Approximately 27 gallons of aviation fuel and about two gallons of sea water were drained from the left tank. The fuselage reservoir sump tanks were filled with sea water. There was no indication of fuel slick observed on the water’s surface during the recovery. A wreckage examination by the airframe and engine manufacturer was conducted with FAA oversight. Flight control continuity was confirmed and no preimpact discrepancies were noted with the airframe that would have prevented normal operation. The engine was impact damaged and revealed saltwater submersion corrosion. The alternator, propeller governor, fuel pump, vacuum pump, and upper sparks plug were removed to facilitate an inspection of the engine. The corrosion prevented a rotational continuity confirmation of the accessory gears, valve train, cylinders, fuel system, ignition system, and induction system. The visual inspection of this engine did not reveal any abnormalities that would have prevented normal operation. Information provided by the pilot and operator to FAA and the manufacturers revealed the airplane began the day’s flight schedule with an estimated 60 gallons of fuel onboard and 10 gallons were later serviced prior to the flight to 35ME. The airplane flew 5 flights prior to the accident; a total of 2.7 hours. The Cessna Pilots Operating Handbook (POH), performance charts, indicates the airplane’s fuel consumption is 16 gallons per hour with two gallons for taxi and takeoff, and one gallon to climb to 2,000 feet for each flight. Utilizing the performance data, the fuel consumption was 58.2 gallons. The airplane’s fuel capacity is 78 gallons usable. The calculated total estimated fuel consumption for the five flights (58.2 gallons) plus the recovered fuel (27 gallons) reflects a total of 85.2 gallons. Based on the operator’s information an exact amount of onboard fuel, and quantities for each fuel tank, could not be determine. The operator’s FAA approved GOM, section 10, Passenger Handling, requires the pilot to give an oral safety briefing before each takeoff, which includes the location of the onboard survival equipment. In addition, a safety information card must be onboard in a location convenient for use by each passenger onboard. Interviews with the passengers revealed no safetybriefing was provided before the takeoff. None of the passengers were aware that life vests or the safety information card were onboard the airplane. As a result of this accident the operator has implemented several changes to their GOM with respect to the fleet’s fueling and tracking onboard fuel quantities, guidance when to make initial engine power reduction after takeoff, revised the onboard passenger’s guide card, mandated pilot’s to read out loud a pre-takeoff briefing referencing to the onboard passenger briefing guide card, modified all the fleet’s airplanes ELT the capability to be activated from the cockpit, equipped the fleet’s airplanes with emergency egress air bailout bottles, mandated all of the company’s pilots to attend a offshore survival training course, and offer the passengers the Mustang personnel flotation device (PFD) to wear during the flight.

Aircraft

Registration
N910TA
Reported as
Cessna U206G
Category
Airplane
Serial number
U20604102
Airframe hours
10,435
Engine
Cont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Penobscot Island Air
Registered owner
Waters Aero-Marine Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 7, 2012 · 2 hours before
Departed
Matinicus Island, ME
Destination
KRKD · Rockland, ME
Flight plan
Company VFR

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
69
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 27, 2010
Seat
Left
Flight hours
25,300 total · 1,000 in this make and model · 18,000 as pilot in command · 40 in the last 90 days · 28 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 6 knots
Visibility
10 statute miles
Temperature
84 °F, dew point 63 °F
Altimeter
29.92 inHg
Observed at
KRKD, 15 nm away

Docket · 21

The files NTSB released with the investigation on September 7, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.4 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 673 KBOther Pertinent Forms and Report: Operator's Accident ReportItem 2 · .PDF · 141 KBMiscellaneous:Excerpts From The Operator's GOM Dispatch Emergency Procedures.Item 3 · .PDF · 115 KBPilot's StatementItem 4 · .PDF · 28 KBRecords of ConversationItem 5 · .PDF · 251 KBMiscellaneous: Excerpts From the Operator's GOM Before the Accident.Item 6 · .PDF · 237 KBReports from Federal Agencies: FAA Inspector's Statement.Item 7 · .PDF · 115 KBExcerpt from Cessna ReportItem 8 · .PDF · 333 KBExcerpt from Continental Motors ReportItem 9 · .PDF · 3.9 MBExcerpt from Airplane's Flight Log RecordsItem 10 · .PDF · 1.4 MBMiscellaneous : Fuel Consumption Calculations, Fueling Recods, & Excerpt from the Airplane's Performance & Fuel System Section)Item 11 · .PDF · 2.4 MBExcerpt from Model U206G Emergency Procedures POH SectionItem 12 · .PDF · 281 KBExcerpt from 206 Series Service Manual Fuel System SectionItem 13 · .PDF · 824 KBExcerpt from Airplane's Maintenance RecordsItem 14 · .PDF · 783 KBStatement of Party Representatives to NTSB InvestigationItem 15 · .PDF · 181 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 16 · .PDF · 55 KBMiscellaneous: Safety Implementation to the Operator's GOM.Item 17 · .PDF · 1.0 MBPhoto 1: Airplane Being Recovered from the Water. Courtesy of the FAA.Item 18 · .PDF · 1.8 MBPhoto 2 : Overview of Airplane After Recovery. Courtesy of the FAAItem 19 · .PDF · 1.9 MBPhoto 3: Airplane in Hangar for Examination. Courtesy of Cessna.Item 20 · .PDF · 2.9 MBPhoto 4: Overview of Airplane as it was Recovered. Courtesy of FAA.Item 21 · .PDF · 3.0 MB

FAA reports on this event · 1

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