# NTSB ERA19IA178: Cessna 550, N744AT, Savannah, GA, May 9, 2019 - Type: NTSB incident investigation - Classification: Incident · No injuries · Class 3 · Incident · Final report - Date: May 9, 2019, 12:28 local (16:28 UTC) - Place: Savannah, GA - Coordinates: 32.129165, -81.200836 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1292&lon=-81.2008&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: No injuries - Injuries: 7 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 99471 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19IA178 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99471/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99471 - Page: https://openairdocs.org/ntsb/ERA19IA178 ## Probable cause The lineman's inadvertent introduction of diesel exhaust fluid (DEF) to the fuel truck fuel system icing inhibitor reservoir, which resulted in fuel contamination and a total loss of engine power. Contributing to the accident was the fixed-base operator's failure to ensure that DEF was stored off-airfield in accordance with their own policy. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Airport personnel (probable cause); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2076604), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Object/animal/substance: ground vehicle](https://openairdocs.org/ntsb-findings/03022025): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/03022025/cases.md?model=2076604), [All aircraft, 132 cases](https://openairdocs.org/ntsb-findings/03022025/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Airport personnel (probable cause); cases with it: [Cessna 550, 3 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2076604), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fluids](https://openairdocs.org/ntsb-findings/01071000): Aircraft › Fluids/misc hardware · Fluid type (probable cause); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/01071000/cases.md?model=2076604), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/01071000/cases.md) - [Fluids](https://openairdocs.org/ntsb-findings/01071000): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/01071000/cases.md?model=2076604), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/01071000/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Airport personnel (probable cause); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=2076604), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/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: Fuel contamination](https://openairdocs.org/ntsb-events/193); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=2076604), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Enroute-cruise: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Cessna 550, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=2076604), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 550, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2076604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 550, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2076604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The crew of the air medical flight reported that, while in cruise flight at 35,000 ft mean sea level, the left engine began losing power. The crew requested a lower altitude from air traffic control, shut down and secured the left engine, and diverted. While descending, the right engine lost all power, and the crew performed an uneventful forced landing to the diversion airport. Several days after the incident, the lineman who worked at the fixed-base operator (FBO) where the airplane was most recently fueled realized that he had inadvertently combined the contents of an unmarked, partially empty container of fuel system icing inhibitor (FSII) with a partially-empty container of diesel exhaust fluid (DEF), assuming that both containers contained FSII. The container of DEF was co-located with the container of FSII, which was contrary to the FBO's policy of isolating DEF off-airfield. The lineman then serviced the fuel truck FSII reservoir with the DEF/FSII combination. The following day, the incident airplane was fueled with Jet A fuel from the truck, and FSII additive from the truck was mixed at the time of fueling. Postincident testing revealed the presence of urea, one of the primary components of DEF, in the incident airplane's fuel system samples. When combined with hydrocarbon jet fuels, urea forms a solid precipitate, or clathrate, that is known to interfere with fuel filtering and fuel system operation. The presence of DEF in the incident airplane's fuel system resulted in a blockage, which led to the total loss of engine power. ## Factual narrative On May 9, 2019, at 1228 eastern daylight time, a Cessna C550, N744AT, experienced a total loss of engine power inflight and landed in Savannah, Georgia, without further incident. The two airline transport pilots, two medical crew, and three passengers onboard were not injured. The flight was operated as a Title 14 Code of Federal Regulations Part 135 air medical flight.The airplane was based at Punta Gorda Airport (PGD), Punta Gorda, Florida. According to fueling records from PGD, on the morning of the incident, the airplane was fueled with 480 gallons of Jet A fuel with a fuel system icing inhibitor (FSII) additive mixed at the time of fueling. The flight crew completed the 47-nautical-mile flight from PGD to Naples Municipal Airport (APF), Naples, Florida, without anomaly. According to the pilots, about 1 hour 20 minutes into the subsequent flight, from APF to Niagara Falls International Airport (IAG), Niagara Falls, New York, while cruising at 35,000 ft mean sea level (msl), the pilot-in-command (PIC) adjusted the left engine N1 speed to about 103%. Moments after adjusting power, the N1 speed decreased. This occurred "a few times" before the left engine began to "spool down very slowly." After unsuccessfully attempting to restore engine power, the crew requested a lower altitude from air traffic control and began a descent with the left engine at idle power. The PIC then noticed that the left engine displayed no oil pressure, and he subsequently shut it down. Several minutes passed as the airplane descended with the right engine at 65% fan speed, and while the crew prepared to perform a single-engine approach to Savannah/Hilton Head International Airport (SAV), Savannah, Georgia, about 8,000 ft msl, the right engine became unresponsive and then began "spooling down." The captain declared an emergency and the crew performed a straight-in approach to runway 19, where they landed the airplane without incident; the airplane was subsequently towed to the ramp. The second-in-command noted that the left fuel filter bypass light did not illuminate, but the right fuel filter bypass light did illuminate. A lineman who worked for the fixed based operator (FBO) at PGD stated that, the evening before the incident, he noticed that the FSII was low on a fuel truck and he intended to refill it. He went to a shed where the FSII was located and noted that the unmarked FSII container was partially filled, and another bottle next to it that was also partially filled. He combined the two containers and then refilled the fuel truck FSII reservoir. Several days after the incident, the lineman realized that he had inadvertently combined the contents of a 5-gallon FSII container and a 2.5-gallon diesel exhaust fluid (DEF) container instead of two partially empty containers of FSII. He could not recall if the DEF container was marked. Fuel samples, fuel system filters, and fuel screens from the incident airplane were obtained and sent for laboratory testing. Analysisof the fuel indicated the presence of urea; DEF is a solution comprised of about 33% urea and 67% water. Although urea is soluble in both water and FSII, when added to hydrocarbon jet fuels, it forms a solid precipitate (known as a "clathrate") that is known to interfere with fuel filtering and fuel system operation. Review of the lineman's training records indicated that he completed National Air Transportation Association (NATA) Fuel Service Supervisor training in July 2018, Professional Line Service training in September 2018, and Line Fuel Service training in September 2018. His training records did not specifically include the DEF Contamination Prevention training released by the NATA in December 2017; however, the lineman did state that he had received DEF training and cross-contamination training in June 2018. The FBO policies in place to mitigate the hazard of DEF contamination before the incident included isolating FSII to the self-serve shed, isolating DEF off-airfield in the vehicle maintenance shop, conducting mandatory training on DEF contamination, and reviewing cross contamination with staff. After the incident, the FBO made multiple changes to their policies, including retraining line personnel, limiting DEF servicing to vehicle maintenance personnel, removing all unmarked containers from storage areas, and creating a monthly inspection program to review all storage facilities for properly stored and labeled inventory. On July 24, 2019, the NTSB issued Safety Alert SA-079 warning providers of jet fuel to take measures to prevent contamination of jet fuel by diesel exhaust fluid. ## Aircraft - Registration: [N744AT](https://openairdocs.org/deregistered/N744AT-2020-02-12), registration cancelled 2020-02-12, S/N 550-0017, built 1983 (OpenAirDocs) - Reported make and model: Cessna 550 (No Series) - Registry model: [Cessna 550](https://openairdocs.org/model/cessna-550) (registry code 2076604) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada JT15D-4 series](https://openairdocs.org/engine/pratt-whitney-canada-jt15d-4-series) (registry code 52112, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 550-0017 - Year built: 1983 - Engines: Pratt & Whitney JT15D-4 2500 lbs thrust turbo jet; Pratt & Whitney JT15D-4 2500 lbs thrust turbo jet - Damage: No damage - Flight: Part 135 - Operator: Air Ambulance By Air Trek Inc - Registered owner: Air Ambulance By Air Trek Inc - Airworthiness certificate: Standard, Transport - Departed: APF, Naples, FL - Destination: IAG, Niagara Falls, NY - Flight plan: IFR - Airport: SAV, Savannah/Hilton Head Intl, runway 19, 7,002 × 150 ft, concrete - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; injuries: none; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: left - Pilot; age 66; injuries: none; commercial, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: helicopter, airplane; medical: class 1, with waivers/limitations; seat: right ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: 3,200 ft broken - Temperature: 79 °F, dew point 66 °F - Altimeter: 30.10 inHg - Observed at: SAV ## Docket (6 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99471. 25.3 MB in all. - Pilots statements (item 1, PDF, 3 pages, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9288437&FileExtension=pdf&FileName=N744AT%20Pilot%20Statements%205-9-19_Redacted-Rel.pdf - Lineman statement and interview summary (item 2, PDF, 3 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9287727&FileExtension=pdf&FileName=Lineman%20Statement%20and%20Interview%20Summary_Redacted-Rel.pdf - Lineman training certificates (item 3, PDF, 6 pages, 21.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9287975&FileExtension=pdf&FileName=Robby%20Burk%20NATA%20Training%20Records_Redacted-Rel.pdf - Airport FBO changes after incident (item 4, PDF, 1 page, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9288670&FileExtension=pdf&FileName=PGD%20FBO%20Mitigation-Rel.pdf - Fuel truck log (item 5, PDF, 1 page, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9288490&FileExtension=pdf&FileName=Truck%20%236%20fuel%20log%2005-09-19-Rel.pdf - Chemical analysis of jet fuel contamination (item 6, PDF, 16 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9288613&FileExtension=pdf&FileName=UDR-TR-2019-80%20-%20Punta%20Gorda%20DEF%20Event-Rel.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.