# NTSB ERA14LA156: Cessna 402B, N419AR, Stuart, FL, March 14, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 14, 2014, 17:30 local (21:30 UTC) - Place: Stuart, FL - Coordinates: 27.060365, -80.27005 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.0604&lon=-80.2700&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report February 4, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 88923 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA156 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88923/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88923 - Page: https://openairdocs.org/ntsb/ERA14LA156 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 402B, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=207590P), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 402B, 3 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=207590P), [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 (probable cause); cases with it: [Cessna 402B, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=207590P), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=207590P), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Approach-VFR pattern final: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 402B, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=207590P), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 402B, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=207590P), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 402B, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=207590P), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 402B, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=207590P), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N419AR-2021-01-09), registration cancelled 2021-01-09, S/N 402B0805, built 1974 (OpenAirDocs) - Reported make and model: CESSNA 402B - Registry model: [Cessna 402B](https://openairdocs.org/model/cessna-402b) (registry code 207590P) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402B0805 - Year built: 1974 - Airframe hours: 5860 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating; CONT 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: minor; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20140314003149A](https://openairdocs.org/incident/20140314003149A), Mar 14, 2014: Cessna 402B, Stuart, FL, Destroyed. The aircraft took off from ft. pierce, Florida, the pilot stated he had approximately 30 gallons of fuel on board the aircraft. The tower gave him a 6 mile… ## Docket (14 files) The files NTSB released with the investigation on January 2, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88923. 10.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420522&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector’s Statement (item 2, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420523&FileExtension=.PDF&FileName=FAA%20Inspector%E2%80%99s%20Statement-Redacted.PDF - Pilot Statement (item 3, .PDF, 768 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420524&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - N419AR ATC Radio Transcription (item 4, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420525&FileExtension=.PDF&FileName=N419AR%20ATC%20Radio%20Transcription-Redacted.PDF - Cessna Party Form (item 5, .PDF, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420526&FileExtension=.PDF&FileName=Cessna%20Party%20Form-Redacted.PDF - Cessna 402B POH Excerpts (item 6, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420527&FileExtension=.PDF&FileName=Cessna%20402B%20POH%20Excerpts-Master.PDF - Stuart Police Report and Witness Statements (item 7, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420528&FileExtension=.PDF&FileName=Stuart%20Police%20Report%20and%20Witness%20Statements-Redacted.PDF - Photo 1 – Right front view of main wreckage (Photo Courtesy of FAA) (item 8, .PDF, 650 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420530&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Right%20front%20view%20of%20main%20wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 – View of right engine (Photo Courtesy of FAA) (item 9, .PDF, 434 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420531&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20View%20of%20right%20engine%20(Photo%20Courtesy%20of%20FAA)%0D%0A-Master.PDF - Photo 3- View of right side aft section of airplane (Photo Courtesy of FAA) (item 10, .PDF, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420532&FileExtension=.PDF&FileName=Photo%203-%20View%20of%20right%20side%20aft%20section%20of%20airplane%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 4: Rear view of airplane (Photo Courtesy of FAA) (item 11, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420533&FileExtension=.PDF&FileName=Photo%204%3A%20Rear%20view%20of%20airplane%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 5: View of left wing of airplane (Photo Courtesy of FAA) (item 12, .PDF, 585 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420534&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20left%20wing%20of%20airplane%20(Photo%20Courtesy%20of%20FAA)%0D%0A-Master.PDF - Photo 6: View of outboard right wing (Photo Courtesy of FAA) (item 13, .PDF, 658 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420535&FileExtension=.PDF&FileName=Photo%206%3A%20View%20of%20outboard%20right%20wing%20(Photo%20Courtesy%20of%20FAA)%09%0D%0A-Master.PDF - Photo 7: View of underside of left wing (Photo Courtesy of FAA) (item 14, .PDF, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420536&FileExtension=.PDF&FileName=Photo%207%3A%20View%20of%20underside%20of%20left%20wing%20(Photo%20Courtesy%20of%20FAA)%0D%0A-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. --- 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.