ERA14TA326

NTSB accident investigation · Cessna 336 · Mobile, AL · July 3, 2014

Accident · Serious injuriesFinal report
Date
July 3, 2014, 18:46 local (23:46 UTC)
Place
Mobile, AL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N3804UCessna 336
Defining event
Maneuvering-low-alt flying: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report April 27, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Textron Aviation, FAA/FSDO, Continental Motors
FAA report
20140703013629A
Case key
89604

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 inadequate preflight fuel planning during which he did not ensure that there was adequate fuel in the main tanks for the flight, which resulted in a loss of engine power.

Findings · 4

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 managementCessna 336: 1 caseAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 336: 1 caseAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionCessna 336: 1 caseAll aircraft: 1,695 cases
Runway/land/takeoff/taxi surface: soft surfaceEnvironmental issues › Physical environment · Contributed to outcomeCessna 336: 1 caseAll aircraft: 264 cases

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

The pilot reported that he was performing mosquito control spraying operations at 100 ft above ground level (agl) when the rear engine began to sputter and lose power. He switched to the auxiliary fuel tank; however, this did not remedy the situation. He then climbed the airplane to 500 ft agl and continued to troubleshoot the problem by again switching fuel tanks and turning the electric boost pumps on. Shortly thereafter, the front engine began to lose power. Unable to regain full power on both engines, the pilot chose to perform a forced landing in an open field. The airplane touched down on soft soil and stopped abruptly, which resulted in extensive damage to the airplane. Both fuel selectors were found in the right main fuel tank positions. An examination of the fuel system revealed that the main fuel tanks contained only residual fuel and that the auxiliary tanks contained an adequate amount of fuel. Examination of the fuel lines revealed that both supply lines from the gascolators to the engine-driven fuel pumps were contaminated and obstructed with a granular, powder-like substance. The engines ran normally when operated in a test cell after the accident. The auxiliary fuel tanks were designed for level, cruise flight only. The auxiliary tanks fed directly to the fuel selector and had no boost pumps available. It is likely that, due to the fuel system's design, adequate fuel pressure could not be regained once the main tanks were depleted and the pilot switched to the auxiliary tanks. The contamination in the fuel lines might have further restricted fuel flow to the engines. The loss of engine power might have been prevented if the pilot had maintained an adequate amount of fuel in the main tanks.

Factual narrative

On July 3, 2014, about 1846 central daylight time, a Cessna 336, N3804U, force landed following a partial loss of engine power at Mobile, Alabama. The airline transport pilot was seriously injured, and the airplane was substantially damaged. The airplane was operated by the Mobile County Health Department. Day, visual meteorological conditions prevailed for the local, public use, aerial application flight, and no flight plan was filed. The local flight originated at St. Elmo, Alabama (2R5) about 1829.The pilot reported in a written statement to the NTSB that he was assigned to mosquito control spraying operations in the Mobile area. He departed 2R5 with about 48 gallons of fuel, including 36 gallons in the auxiliary tanks. While established on the southbound leg of a spray pattern, he transferred the engines, one at a time, to the full, 18 gallon auxiliary tanks. Shortly after, the engines began to "sputter" and would not maintain rpm. He aborted the spray run, "zoom climbed" to about 600 feet above the ground (agl), and turned to a heading of about 210, in the direction of Mobile Downtown Airport (BFM), about 4 to 5 nautical miles away. The available power was intermittent with rpm surges on both engines, and power available appeared insufficient to reach BFM. He set up for a forced landing on an island between a container terminal and a coal terminal. The airplane touched down on soft soil and came to a stop abruptly, resulting in extensive damage to the airplane. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. Structural damage to the fuselage was confirmed. An examination of the fuel system revealed that the fuel selector handle for the front engine was in the right main tank position. The fuel selector handle for the rear engine was broken off from impact forces. It was later determined that the rear engine fuel selector was also in the right main tank position. The left and right main fuel tanks were empty of fuel and only residual fuel (about 2 ounces) was drained from the left and right main sump tanks. The tanks were not breached. The design of main fuel tanks allows them to completely drain into their respective sump tanks. The left and right auxiliary tanks contained sufficient fuel; however, it was not quantified. The FAA inspector interviewed the pilot on July 9, 2014. He stated in the interview that he had been flying at 100 feet agl when the rear engine began "sputtering and coughing." He switched to the auxiliary fuel tank; however, this did not remedy the situation. He climbed the airplane to 500 feet agl and continued to troubleshoot by switching tanks and turning the boost pumps on. The front engine then began to lose power. He continued to troubleshoot the loss of power and realized that he could not maintain altitude and needed to perform an emergency landing short of the airport. The engines were removed from the airframe and sent to the manufacturer's facilityfor examination. The engines were test run during the week of July 21 through 25, 2014. After repair of impact-related damage, the engines ran normally in a test cell. The test runs did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower. On January 16, 2015, the aircraft fuel system was re-examined under the supervision of the NTSB investigator-in-charge. The both engine fuel selectors were confirmed to be in the right main tank positions. Flaky, rust-colored debris was observed inside the right sump tank. The left sump tank was relatively clean. The left and right wing auxiliary fuel pumps, which operate the left and right main tank fuel sources only, were found to be functional when energized with a dc electrical source. The fuel lines from the fuel selector valves to the main and auxiliary tanks were unobstructed. The rear engine fuel strainer was opened for examination. It contained about 1/8 teaspoon of light gray, powder-like debris in the bowl. The screen was unobstructed. The supply line from the strainer to the engine-driven fuel pump was obstructed; no air could be blown through it by mouth. The obstruction was removed with a clean piece of wire; about one teaspoon of light gray, powder-like debris was removed. The front engine fuel strainer was opened for examination. The bottom of the bowl was corroded with a rust-like substance. The screen was unobstructed. The supply line from the strainer to the engine-driven fuel pump was obstructed; no air could be blown through it by mouth. The obstruction was removed with a clean piece of wire; about one half teaspoon of rust-colored, granular debris was removed. According to the aircraft manufacturer, the auxiliary fuel tanks are intended for level, cruise flight. The auxiliary fuel tanks gravity feed directly to the fuel strainer; no boost pumps are available. The Cessna 336 pilot's operating handbook (POH) states that, in the pre-flight exterior inspection and the before landing checklist, the main tanks are to be selected. Also, the POH states that, in the event of an engine out situation during flight, the main tanks are to be selected if the auxiliary tanks are in use.

Aircraft

Registration
N3804U
Reported as
Cessna 336
Category
Airplane
Serial number
336-0104
Built
1964
Airframe hours
3,151
Engines
Cont Motor IO-360 SER, 210 horsepower, reciprocatingCont Motor IO-360 SER, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial application · Public use
Operator
Mobile County Health Department
Registered owner
Mobile County Health Department
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · April 2, 2014
Departed
2R5 · St. Elmo, AL
Destination
2R5 · St. Elmo, AL
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
67
Injuries
Serious
Certificates
Flight instructor, Airline transport, Flight engineer
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 7, 2013
Seat
Left
Restraint
Lap only
Flight hours
19,000 total · 16 in this make and model · 10,000 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 5 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
82 °F, dew point 72 °F
Altimeter
30.04 inHg
Observed at
MOB, 11 nm away

Docket · 24

The files NTSB released with the investigation on March 31, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 27.7 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 1.4 MBFAA Inspector StatementItem 2 · .PDF · 16 KBExcerpts – Airframe LogbookItem 3 · .PDF · 1.1 MBExcerpts – Forward Engine LogbookItem 4 · .PDF · 458 KBExcerpts – Rear Engine LogbookItem 5 · .PDF · 357 KBDocumentation of Annual InspectionItem 6 · .PDF · 1.5 MBNTSB Memorandum of Record MOB WeatherItem 7 · .PDF · 122 KBContinental Motors Front and Rear Engine Run ReportsItem 8 · .PDF · 3.6 MBStatement of Party Representatives to NTSB InvestigationItem 9 · .PDF · 496 KBEvidence ControlItem 10 · .PDF · 183 KBPhoto 1 – View of Aircraft Wreckage from Left Side (Photo Courtesy of FAA)Item 11 · .PDF · 2.2 MBPhoto 2 – View of Aircraft Wreckage from Aft (Photo Courtesy of FAA)Item 12 · .PDF · 1.8 MBPhoto 3 – View of Aircraft Wreckage from Right Side (Photo Courtesy of FAA)Item 13 · .PDF · 1.5 MBPhoto 4 – View of Aircraft Wreckage from Front (Photo Courtesy of FAA)Item 14 · .PDF · 2.2 MBPhoto 5 – View of Forward Fuselage and Front Engine (Photo Courtesy of FAA)Item 15 · .PDF · 2.2 MBPhoto 6 – View of Aft Fuselage and Rear Engine (Photo Courtesy of FAA)Item 16 · .PDF · 1.4 MBPhoto 7 – Cockpit Engine Controls (Photo Courtesy of FAA)Item 17 · .PDF · 1.7 MBPhoto 8 – Cockpit Fuel Selector Handles (Photo Courtesy of FAA)Item 18 · .PDF · 1.7 MBPhoto 9 – Rear Engine Fuel Supply Line DebrisItem 19 · .PDF · 854 KBPhoto 10 – Rear Engine Fuel Strainer BowlItem 20 · .PDF · 516 KBPhoto 11 – Debris Found Inside Rear Engine Fuel Strainer BowlItem 21 · .PDF · 891 KBPhoto 12 – Debris Inside Right Main Sump TankItem 22 · .PDF · 483 KBPhoto 13 – Front Engine Fuel Supply Line DebrisItem 23 · .PDF · 607 KBPhoto 14 – Front Engine Fuel Strainer CorrosionItem 24 · .PDF · 552 KB

FAA reports on this event · 1

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