# NTSB ERA18LA033: Cessna 421, N421RX, Presque Isle, ME, November 22, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: November 22, 2017, 18:45 local (23:45 UTC) - Place: Presque Isle, ME - Coordinates: 46.688888, -68.044723 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.6889&lon=-68.0447&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: Minor injuries - Injuries: 2 minor, 2 uninjured - Status: Completed, report July 23, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 96398 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96398/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96398 - Page: https://openairdocs.org/ntsb/ERA18LA033 ## Probable cause The in-flight leakage of fuel from the fuel injection system's mixture shaft onto the hot turbocharger, which resulted in an in-flight fire, and the pilot's inability to see the runway due to reduced visibility conditions and conduct a successful landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel controlling system](https://openairdocs.org/ntsb-findings/01057320): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Cessna 421C, 1 case](https://openairdocs.org/ntsb-findings/01057320/cases.md?model=2076016), [All aircraft, 59 cases](https://openairdocs.org/ntsb-findings/01057320/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=2076016), [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. - [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=2076016), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Approach-VFR pattern final: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2076016), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Initial climb: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna 421C, 2 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2076016), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338); cases with it: [Cessna 421C, 5 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=2076016), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) ## Analysis After takeoff, the commercial pilot saw flames coming from the left engine nacelle area. He retarded the throttle and turned off the fuel boost pump; however, the fire continued. He then feathered the propeller, shut down the engine, and maneuvered the airplane below the clouds to remain in the local traffic pattern. He attempted to keep the runway environment in sight while drifting in and out of clouds. He was unable to align the airplane for landing on the departure runway, so he attempted to land on another runway. When he realized that the airspeed was decreasing and that the airplane would not reach the runway, he landed it on an adjacent grass field. After touchdown, the landing gear separated, and the airplane came to a stop. The airframe sustained substantial damage to the wings and lower fuselage. Examination of the left engine revealed evidence of a fuel leak where the fuel mixture control shaft inserted into the fuel injector body, which likely resulted in fuel leaking onto the hot turbocharger in flight and the in-flight fire. A review of recent maintenance records did not reveal any entries regarding maintenance or repair of the fuel injection system. The pilot reported clouds as low as 500 ft with rain, snow, and reduced visibility at the time of the accident, which likely reduced his ability to see the runway and maneuver the airplane to land on it. ## Factual narrative On November 22, 2017, about 1845 eastern standard time, a Cessna 421C, N421RX, was substantially damaged during a forced landing shortly after takeoff from Northern Maine Regional Airport (PQI), Presque Isle, Maine. The commercial pilot was not injured; two crewmembers, and one passenger sustained minor injuries. The airplane was operated by Fresh Air LLC under the provisions of Title 14 Code of Federal Regulations part 135 as an air medical flight. Day, instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight originated at PQI about 1840 and was destined for Bangor International Airport (BGR), Bangor, Maine.The pilot reported that the preflight inspection of the airplane and ground operations were uneventful. After taking off on runway 19, the pilot retracted the landing gear and turned off the landing lights. He then observed flames coming from the left engine nacelle. He immediately retarded the throttle and turned off the fuel boost pump; however, the fire persisted. He feathered the propeller, shut down the engine, and maneuvered the airplane below the clouds to remain in the traffic pattern at PQI. He attempted to keep the runway environment in sight while drifting in and out of clouds. He was unable to align the airplane for a landing on runway 19, so he attempted to land on runway 10. The pilot realized the airspeed was dropping and the airplane would not reach runway 10, so he landed in an adjacent field. After touchdown, the landing gear broke away and the airplane came to a stop in the grass. The PQI reported weather at 1848 included, overcast clouds at 1,400 ft and broken clouds at 800 ft, with 5 statute miles visibility in light snow and mist. The pilot reported that the clouds were at 500 ft with rain and snow at the time of the accident. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. The airplane came to rest in an upright position. The landing gear were separated, and structural damage to the wings and lower fuselage was evident. Initial examination of the left engine revealed soot on the nacelle louver vents and some localized white discoloration near the turbocharger area. Subsequent examination of the engine revealed soot and a darkening of the area below and behind the fuel injector system near the turbocharger. The top engine cowling, which exhibited paint bubbling and discoloration from exposure to intense heat, was placed over the top of the engine and the damage was consistent with the area above the fuel injector system. The fuel system was then pressurized with 40psi of air and the sound of escaping air was heard in and around the mixture control arm of the fuel injector system. A mixture of water/soap was sprayed on the area where air was heard, and bubbles were immediately observed. Other areas of the engine were also sprayed with the water/soap mixture and no other signs of leaks were observed. Thearea where the leak was observed was consistent with fuel dripping and being blown onto the hot turbocharger in flight. The fuel injector system was removed, and blue staining was observed in and around the mixture arm. A pressure check of the exhaust system was also conducted. No leaks were observed at any welds or joints. A review of the engine logbook entries did not reveal evidence of any recent maintenance or repair on the fuel injection system. An annual inspection was completed on June 2, 2017 and a 100-hr inspection was completed on September 13, 2017. ## Aircraft - Registration: [N421RX](https://openairdocs.org/deregistered/N421RX-2023-04-01), registration cancelled 2023-04-01, S/N 421C0264 (OpenAirDocs) - Reported make and model: CESSNA 421 (C) - Registry model: [Cessna 421C](https://openairdocs.org/model/cessna-421c) (registry code 2076016) (OpenAirDocs) - Registry engine: [Continental GTSI0-520-F-K](https://openairdocs.org/engine/continental-gtsi0-520-f-k) (registry code 17031, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 421C0264 - Year built: 1977 - Airframe hours: 7473 - Engines: CONT MOTOR GTSIO-520-L 375 horsepower reciprocating; CONT MOTOR GTSIO-520-L 375 horsepower reciprocating - Damage: Substantial damage - Fire: In-Flight - Flight: Part 135 - Operator: Fresh Air LLC - Registered owner: Fresh Air LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 2, 2017, 18 hours before - Departed: PQI, Presque Isle, ME - Destination: BGR, Bangor, ME - Flight plan: IFR - Airport: PQI, Northern Maine Regional - Equipment: Stall warning system, Auto-pilot, Handheld GPS, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: minor; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review June 28, 2017; seat: left; restraint: 3-point; flight hours: 4,482 total, 3,620 in this make and model, 3,973 as pilot in command, 73 in the last 90 days, 29 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 310° at 3 knots - Visibility: 5 statute miles - Lowest ceiling: 800 ft broken - Temperature: 34 °F, dew point 34 °F - Altimeter: 29.81 inHg - Observed at: PQI ## 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 20171122019679A](https://openairdocs.org/incident/20171122019679A), Nov 22, 2017: Cessna 421C, Presque Isle, ME, Substantial damage. The following summary of events is taken from a written statement provided by the PIC: aircraft performed normally during takeoff roll. Once airborne, the… ## Docket (5 files) The files NTSB released with the investigation on December 21, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96398. 7.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469789&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Written Statement (item 2, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469790&FileExtension=.PDF&FileName=Pilot%27s%20Written%20Statement-Master.PDF - Left Engine Logbook Excerpts (item 3, .PDF, 602 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469791&FileExtension=.PDF&FileName=Left%20Engine%20Logbook%20Excerpts%20-Master.PDF - Photo Array (item 4, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469792&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - NTSB Engine Examination Report (item 5, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469793&FileExtension=.PDF&FileName=NTSB%20Engine%20Examination%20Report-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.