# NTSB ERA21LA196: Cessna 402C, N2714B, Hyannis, MA, April 26, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: April 26, 2021, 15:26 local (19:26 UTC) - Place: Hyannis, MA · On Airport - Coordinates: 41.669333, -70.280361 - Nearby events: https://openairdocs.org/map.md?lat=41.6693&lon=-70.2804&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - 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 - NTSB case key (mKey): 103000 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA196 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103000/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103000 - Page: https://openairdocs.org/ntsb/ERA21LA196 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Communication (personnel): issuing instructions](https://openairdocs.org/ntsb-findings/02063538): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 402C, 1 case](https://openairdocs.org/ntsb-findings/02063538/cases.md?model=207590R), [All aircraft, 26 cases](https://openairdocs.org/ntsb-findings/02063538/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 402C, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=207590R), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Cessna 402C, 1 case](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=207590R), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Cessna 402C, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=207590R), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Approach-VFR go-around: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 402C, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=207590R), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 402C, 1 case](https://openairdocs.org/ntsb-events/092/sequence.md?model=207590R), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## 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](https://openairdocs.org/deregistered/N2714B-2022-07-30), registration cancelled 2022-07-30, S/N 402C0210 (OpenAirDocs) - Reported make and model: CESSNA 402C - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Category: Airplane - Serial number: 402C0210 - Year built: 1979 - Airframe hours: 38774.8 - 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 74; injuries: none; 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 - Pilot; age 30; injuries: none; 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 ## 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 20210426012489A](https://openairdocs.org/incident/20210426012489A), Apr 26, 2021: Cessna 402C, Hyannis, MA, Substantial damage. While conducting a low approach to runway 33 the instructor told the trainee to "go-around". Approximately 600-700 feet during the go-around, the instructor… ## Docket (7 files) The files NTSB released with the investigation on August 19, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103000. 12.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12527515&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - NTSB record of conversation - training captain (item 2, PDF, 1 page, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12529520&FileExtension=pdf&FileName=NTSB%20ROC%20-%20Training%20Captain%20Cape%20Air-Rel.pdf - NTSB record of conversation - trainee (item 3, PDF, 2 pages, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12529278&FileExtension=pdf&FileName=NTSB%20ROC%20-%20Trainee%20Cape%20Air-Rel.pdf - FAA inspector's engine examination report (item 4, PDF, 1 page, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12527057&FileExtension=pdf&FileName=FAA%20Inspector%27s%20Report%20-%20Engine%20Exam-Rel.pdf - Survellance video file - approach (item 5, AVI, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12553547&FileExtension=avi&FileName=ACC%20Export%20approach%20-%202021-08-03%2004.27.55%20PM_b_converted-Rel.avi - Surveillance video file - approach 2 (item 6, AVI, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12553659&FileExtension=avi&FileName=ACC%20Export%20East%20Ramp-%202021-08-03%2004.35.16%20PM_b_converted-Rel.avi - Photos (item 7, PDF, 2 pages, 2 photos, 848 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12526914&FileExtension=pdf&FileName=Photo%20Array%20HYA-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.