ERA14LA156

NTSB accident investigation · Cessna 402B · Stuart, FL · March 14, 2014

Accident · Minor injuriesLimited investigationFinal report
Date
March 14, 2014, 17:30 local (21:30 UTC)
Place
Stuart, FL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N419ARCessna 402B
Defining event
Approach-VFR pattern final: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed · report February 4, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA
FAA report
20140314003149A
Case key
88923

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

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Probable cause

The pilot’s improper preflight planning and fuel management, which resulted in a total loss of power in both engines due to fuel exhaustion.

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 402B: 4 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 402B: 3 casesAll aircraft: 719 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

According to the pilot, he checked the fuel gauges before departure and believed he had enough fuel for the flight. As he approached his destination airport, he was instructed by an air traffic controller to enter a 2-mile left base. About 3 miles from the airport, the controller advised him to intercept a 6-mile final. About 1 1/2 miles from the runway, the left engine "quit." The pilot repositioned the fuel valve to the left inboard fuel tank and was able to restart the engine, but, shortly after, the right engine "quit." He then attempted to reposition the right fuel valve to the right inboard fuel tank to restart the right engine, but the left engine "quit" again, and the pilot subsequently made a forced landing in a field. An examination of the engine and airplane systems revealed no anomalies that would have precluded normal operation. The left wing fuel tanks were found empty. The right wing was found separated from the fuselage. No evidence of fuel was noted in the right wing fuel tanks, and no evidence of fuel leakage was found at the accident site. The pilot reported that he saw fuel leaking out of the right wing fuel vent after the accident; it is possible that a small quantity of the airplane's unusable fuel for the right tank could have leaked out immediately after the accident. Although the pilot believed that the airplane had enough fuel onboard for the flight, his assessment was based on his calculations of the airplane's fuel burn during several short flights he made after having the airplane topped off with fuel the night before the accident; he did not visually check the fuel level in the tanks before departing on the accident flight. The lack of fuel in the fuel tanks, the lack of evidence of fuel leakage, the loss of engine power in both engines, and the lack of mechanical anomalies are consistent with fuel exhaustion.

Factual narrative

On March 14, 2014, about 1730 eastern daylight time, a Cessna 402B, N419AR, was substantially damaged when it collided with terrain while making a forced landing following loss of power in both engines while on short final approach to Witham Field Airport, Stuart, Florida. The commercial pilot sustained minor injuries. The airplane was registered to and operated by the commercial pilot under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The flight departed from St. Lucie County International Airport (FPR), Fort Pierce Florida at 1705. According to the pilot, prior to departing he checked the fuel gauges and determined that he had approximately 28 gallons of fuel onboard, which he calculated as 1 hour of flight time. He did not indicate that he visually checked the fuel level in the tanks before departure. As he approached his destination airport he was instructed by air traffic control (ATC) to enter a 2 mile left base. Approximately 3 miles from the airport, ATC advised him to intercept a 6 mile final. The pilot stated that, at the time, he wasn't aware he had a fuel shortage situation. After turning final, the pilot configured the airplane for landing, and approximately one and a half miles from the runway, the left engine "quit." The pilot elected not to feather the left propeller because it would take six seconds to complete. Instead, he turned the left fuel valve to the left inboard fuel tank and the left engine restarted successfully; however, the right engine then "quit." The pilot then attempted to turn the right fuel valve to the right inboard tank, but the left engine quit again. The pilot made a forced landing in a field and impacted a tree before colliding with the ground, which resulted in substantial damage to both wings and the fuselage. The pilot stated that, upon exiting the airplane, he saw that a section of the right wing was inverted and "fuel was coming out of the right vent." The Federal Aviation Administration (FAA) inspector who responded to the scene about 3.5 hours after the accident reported that he did not detect any fuel odor at the scene and that examination of the airplane revealed no evidence of fuel leakage. The FAA inspector stated that a law enforcement officer on scene informed him that the fire department personnel who responded to the scene did not spray any foam on the airplane because there was no fuel leaking from it. Examination of the engines by the FAA revealed that due to external damage, an engine run could not be performed on either engine. An examination of the engines revealed that both engines were rotated by hand and valve train continuity and cylinder compression was obtained. Further examination revealed that spark was obtained on all ignition leads. Examination of the aircraft systems did not revealed any anomalies that would have precluded normal operation. Examination of the leftwing tanks revealed that they were void of fuel. The right wing was separated from the fuselage and, although they were breached, no evidence of fuel was noted in any of the right wing tank. In the pilot's written statement submitted to the NTSB, he indicated that the airplane was topped off with fuel the night before the accident. His statement described that, on the day of the accident, he flew several short flights before the accident flight. He provided his fuel endurance calculation for the airplane with full fuel then subtracted the "flight time" for each of the previous flights from that total endurance time to determine that, before departing on the accident flight, the airplane should have had "2 hours 23 minutes fuel left, without takeoff and landing." The pilot explained the approaches for each of these flights and indicated that he taxied to the ramp to pick up and drop off friends at each destination.

Aircraft

Registration
N419AR
Reported as
Cessna 402B
Category
Airplane
Serial number
402B0805
Built
1974
Airframe hours
5,860
Engines
Cont Motor TSIO-520 SER, 300 horsepower, reciprocatingCont Motor TSIO-520 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Marlin Moudy
Registered owner
Mardon Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2014
Departed
FPR · Fort Pierce, FL
Destination
SUA · Stuart, FL
Airport
SUA · Witham Field Airport
Equipment
Stall warning system

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
71
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
16,000 total · 8,000 in this make and model · 45 in the last 90 days · 35 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 12 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 43 °F
Altimeter
30.21 inHg
Observed at
SUA, 1 nm away

Docket · 14

The files NTSB released with the investigation on January 2, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.8 MB in all.

FAA reports on this event · 1

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