ERA21LA196

NTSB accident investigation · Cessna 402C · Hyannis, MA · April 26, 2021

Accident · No injuriesClass 4 · LimitedFinal report
Date
April 26, 2021, 15:26 local (19:26 UTC)
Place
Hyannis, MA · On Airport
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2714BCessna 402C
Defining event
Approach-VFR go-around: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20210426012489A
Case key
103000

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 flight instructor’s failure to confirm the position of the left engine’s auxiliary fuel boost pump switch during a simulated engine out procedure, which resulted in an excess amount of fuel in the engine and subsequent partial loss of power during a go-around/rejected landing. Contributing to the accident was the flight instructor’s failure to maintain control of the airplane, which resulted in a hard landing.

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.

Communication (personnel): issuing instructionsPersonnel issues › Task performance · Instructor/check pilotCessna 402C: 1 caseAll aircraft: 26 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotCessna 402C: 5 casesAll aircraft: 9,295 casesProbable cause
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotCessna 402C: 1 caseAll aircraft: 200 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

A flight instructor and a new-hire trainee pilot were practicing instrument approach procedures in the multi-engine airplane. The first approach was a circle-to-land that terminated with a go-around/rejected landing. On climb out, the flight instructor reduced power on the left engine to simulate an engine failure on takeoff. The pilot then ran the memory items for an engine failure, which included turning the left engine auxiliary fuel boost pump to high. Air traffic control then vectored the airplane for another instrument approach. The approach terminated with the pilot making visual contact with the runway and preparing to land. When the airplane was about 50 ft above the runway, the flight instructor called for a two-engine go-around. The pilot brought both throttles to full power and retracted the flaps and gear. The flight instructor said the airplane yawed left, and the airspeed was about 80 knots, well under the airplane’s best single engine rate of climb speed of 95 knots. The flight instructor took control of the airplane and called for the gear to be extended. He told the pilot that he was going to land on the grass. The airplane landed hard and rolled before the nose and left main landing gear collapsed, resulting in substantial damage to the left engine and wing. Prior to exiting the airplane, the pilot said he turned the left engine auxiliary boost pump from the high position to the off position. The flight instructor said that turning the boost pump to high while the engine was still operating could flood the engine with excess fuel and cause it to lose power. He said that he normally reminds pilots not to turn the pump to high during a simulated engine failure in flight, but neither he nor the pilot recalled it being mentioned during the accident flight. Postaccident examination of the left engine revealed no mechanical discrepancies that would have precluded normal operation. As a result, its most likely that when the boost pump was turned to high, it flooded the engine with excess fuel, resulting in loss of engine power while attempting to go around. The flight instructor and the pilot were not prepared for the loss of engine power and the airspeed dropped well below the airplane’s best single engine rate of climb speed of 95 knots. Due to the low airspeed and altitude, the flight instructor took control of the airplane and landed on the grass adjacent to the runway. The pilot said that he had practiced simulated engine out procedures in the simulator, but never in the airplane. In the simulator, he was taught to physically move the auxiliary boost pump to the high position when practicing a simulated engine failure. He was not aware that turning the auxiliary fuel boost pump to high could result in a loss of engine power.

Aircraft

Registration
N2714B
Reported as
Cessna 402C
Category
Airplane
Serial number
402C0210
Built
1979
Airframe hours
38,774.8
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Hyannis Air Service, doing business as Cape Air
Registered owner
Hyannis Air Service
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · April 12, 2021
Destination
Same as departure
Airport
HYA · Cape Cod Gateway, runway 06/24, 5,425 × 150 ft, asphalt
Equipment
ADS-B, Auto-pilot, 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
74
Injuries
None
Certificates
Airline transport, Commercial, Flight instructor, Private
Airplane ratings
Multi-engine land, Multi-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
December 4, 2020
Seat
Right
Restraint
3-point
Flight hours
20,000 total · 10,500 in this make and model · 19,900 as pilot in command · 86 in the last 90 days · 56 in the last 30 days · 4 in the last 24 hours
Role
Pilot
Age
30
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
1,538 total · 5 in this make and model · 1,388 as pilot in command · 5 in the last 90 days · 5 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 11 knots, gusting 18
Visibility
10 statute miles
Temperature
54 °F, dew point 32 °F
Altimeter
29.81 inHg
Observed at
HYA

Docket · 7

The files NTSB released with the investigation on August 19, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.6 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.