# NTSB ERA24FA301: Cessna 402B, N4167G, Aguadilla, PR, July 11, 2024 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 11, 2024, 09:23 local (13:23 UTC) - Place: Aguadilla, PR · Residential - Coordinates: 18.505987, -67.112265 - Nearby events: https://openairdocs.org/map.md?lat=18.5060&lon=-67.1123&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern crosswind: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 1 fatal, 1 minor; on the ground: 1 minor - Status: Completed, report May 13, 2026 - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, Continental Aerospace Technologies, FAA/FSDO - NTSB case key (mKey): 194672 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA24FA301 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194672/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=194672 - Page: https://openairdocs.org/ntsb/ERA24FA301 ## Probable cause The pilot’s decision to operate the airplane with known maintenance discrepancies, which resulted in a total loss of right engine power. Contributing to the outcome was the pilot’s failure to maintain airspeed while returning to the airport with a single operating engine, which resulted in a loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 402B, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=207590P), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 402B, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=207590P), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 402B, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=207590P), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Maintenance/inspections: return to service](https://openairdocs.org/ntsb-findings/01010530): Aircraft › Aircraft handling/service · Not serviced/maintained (probable cause); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-findings/01010530/cases.md?model=207590P), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/01010530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern crosswind: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 402B, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=207590P), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Approach-VFR pattern crosswind: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna 402B, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=207590P), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-VFR pattern downwind: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 402B, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=207590P), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis About 3 months before the accident, the twin-engine airplane underwent an annual maintenance inspection during which the mechanic identified numerous discrepancies with both engines and the airframe. The airplane was not subsequently approved for flight and the owner was provided a list of the discrepancies. The purpose of the accident flight was to relocate the airplane to another airport where the pilot planned to have the discrepancies addressed. The mechanic reported that he had advised the pilot that he needed to apply for a ferry permit from the FAA in order to complete the accident flight, but there was no evidence that the pilot had obtained one. On the day of the accident flight, air traffic control data showed that the pilot departed and climbed the airplane to about 1,500 ft mean sea level (msl). About 2 miles from the departure airport the pilot advised air traffic control of his intent to return to the departure runway due to a vibration of the right engine. The controller immediately cleared the pilot to enter the left downwind for the departure runway. The airplane then turned to the left and began a descent toward the left downwind leg of the traffic pattern. When the airplane was about a mile from the airport, the pilot reported that the airplane had an “engine failure” and that he intended to land on the departure runway, but in the opposite direction. Recorded flight track data showed that the airplane then turned directly toward the approach end of that runway and that during the final 30 seconds of track data, the airplane’s altitude and groundspeed decreased rapidly. Surveillance video captured the final few seconds of flight, and showed the airplane in a steep vertical descent and a right roll. The airplane impacted a residential area into trees, powerlines, and propane fuel tanks. After the impact, the airplane sustained significant postimpact fire damage. Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures of the airplane’s flight controls. Although the right engine’s fuel manifold was damaged by thermal forces, it contained visible corrosion and remains of diaphragm material when opened. Below the fuel screen at the fuel inlet within the manifold was a large quantity of debris and foreign material that was likely present before the accident. Based on the available evidence, it is possible that this contamination resulted in the total loss of engine power to the right engine that was reported by the pilot; however, given the multiple discrepancies that had been documented with the engine prior to the flight, and the extent of the post impact fire damage to the engine, it is possible that the loss of reported loss of engine power may have been due to other unresolved maintenance issues. The final recorded position showed the airplane about .3 miles the runway threshold at 200 ft msl and 73 kts groundspeed, on a heading of 209°. The Pilot’s Operating Handbookfor the accident airplane model listed the minimum controllable airspeed as 82 knots indicated airspeed. Considering the wind information provided by air traffic control to the pilot of 090° at 10 knots, gusting to 14 knots, it is likely that the airplane’s airspeed likely decreased below its minimum controllable airspeed which resulted in a loss of control from which the pilot was not able to recover. ## Factual narrative According to the Cessna Model 402B Pilot’s Operating Handbook (POH), section 3, “Emergency Procedures,” the recommended safe single-engine speed was 91 knots indicated air speed (KIAS). The minimum controllable airspeed was listed as 82 KIAS. Furthermore, the POH procedure Engine Failure After Takeoff (Speed Above 91 KIAS with Gear Up or In Transit) listed the following as “immediate action items” that “should be committed to memory”: 1. Mixtures – FULL RICH 2. Propellers – FULL FORWARD 3. Throttles – FULL FORWARD (34.5 Inches Hg.) 4. Landing gear – CHECK UP 5. Inoperative engine: a. Throttle – CLOSE b. Mixture – IDLE CUT-OFF c. Propeller – FEATHER. It then stated to establish a bank of 5° toward the operative engine. The airplane’s maintenance records included an annual inspection maintenance endorsement, dated April 24, 2024 (about 11 weeks before the accident), which denoted that the airplane was “UNAIRWORTHY.” Attached to the endorsement was a discrepancy sheet that had 3 pages of items to be corrected, including discrepancies with both engines and the airframe. Some items annotated on the discrepancy sheet included left and right fuel tank caps that required replacement (annotated “Done”), one of the right engine’s cylinders below a compression of 45 psi, all right engine’s spark plugs needing replacement, the right engine’s oil and oil filter needing replacement, the right engine’s fuel filter needing replacement, the right engine’s and oil an fuel lines needing replacement (due to time in service and date). The airplane had not been signed off for an annual or 100-hr inspection after the April 11, 2024, inspection. According to the mechanic who wrote the list, the majority of the items had not been corrected. This mechanic advised the pilot that he needed to apply for a ferry permit from the FAA in order to complete the flight to SJU. No documentation was available showing that the pilot had ferry permit had been obtained prior to the accident flight. From November 2020 to April 2024, the maintenance records showed that the airplane had flown 1.4 hours. The most recent annual/100-hr inspection endorsement that found the airplane in an airworthy condition was dated June 6, 2019. The maintenance records indicated that the left engine was overhauled on December 14, 2011, and the right engine was field overhauled on October 24, 2008. According to the current revision of Continental Motors Service Information Letter SIL98-9, the recommended engine time between overhaul for the TSIO-520-E engine was 1,400 hours or 12 years, whichever occured first. As of November 2020, the left engine had accumulated 400.3 hours since overhaul. As of June 2019, the right engine had accumulated 1,400.0 hours since overhaul. According to FAA records, the airplane was purchased by the registered owner in August 2016. On July 11, 2024, about 0923 Atlantic standard time, a Cessna 402B airplane, N4167G, was destroyed when was involved in an accident near the RafaelHernandez Airport (BQN), Aguadilla, Puerto Rico. The private pilot was fatally injured, and a person on the ground sustained minor injuries. The airplane was operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to a mechanic who assisted the pilot with his preflight inspection, the pilot planned to complete the flight from his home airport, BQN, to Luis Munoz Marin International Airport (SJU), San Juan, Puerto Rico, where he planned to have several maintenance discrepancies addressed. The mechanic reported that the four fuel tanks were found near empty or about one-third full during the preflight inspection. A fuel receipt showed that the pilot purchased 13 gallons of 100LL AvGas before the accident flight. The mechanic reported that, after the fuel was added, the left main fuel tank contained about 15 gallons and the right main fuel tank contained about 6-8 gallons. He estimated that the left auxiliary tank contained about 20 gallons and the right auxiliary tank contained about 15 gallons. He did not observe the pilot sump the fuel tanks during the preflight inspection and the correct fuel measuring dip stick was not present with the airplane. He reported that the pilot told him that he planned to use the main tanks for takeoff and then the auxiliary tanks while enroute. The mechanic observed the pilot start the engines and complete a normal engine run-up, but did not witness the airplane take off. FAA ADS-B data showed that the airplane departed runway 8 and climbed to about 1,500 ft mean sea level (msl) about 2 miles east of the approach end of runway 8. The airplane then made a turn to the left and began a descent. When the airplane reached about one mile northeast of the airport, the track turned directly toward the approach end of runway 26. In the final 30 seconds of track data, the altitude and groundspeed continued to decrease rapidly. The final track data point showed the airplane about .3 miles northeast of the runway 26 threshold at 200 ft msl and 73 knots groundspeed, on a heading of 209°. Review of FAA air traffic control (ATC) ground and tower communications found that about 0914 the pilot requested a visual flight rules (VFR) departure to the east and about 3 minutes later was cleared for takeoff from runway 8. At 0921:31, the pilot called the tower and stated, “yeah going back to runway 8 I just wanna check the uh vibration on the right engine uh uh no emergency for right now for 1 6 7 gulf” (see figure). The controller immediately cleared the pilot to enter the left downwind for runway 8 and provided him with the current weather and airport information. At 0922:25, the pilot stated “aguadilla ground mayday mayday I I engine failure I will use the other side of the runway for 1 6 7 gulf.” The controller immediately cleared the pilot to land on runway 26 and provided him the current wind information of 090° at 10 kts, gusting to 14 kts. The pilot read backcleared to land and there were no further communications. Figure: Overview of the airplane's flight path and excerpts of the pilot's communication with the ATC tower Two air traffic controllers observed the airplane’s flight path as it was flying directly toward the runway 26 threshold. They observed the airplane in its final few seconds of flight abruptly roll to the right and descend vertically into terrain. Before the descent, one controller reported that he did not observe anything abnormal about the airplane. Surveillance video captured the final few seconds of flight, which showed the airplane in a steep vertical descent and right roll with the landing gear retracted. After impact, an explosion and postaccident fire were observed. One person on the ground, who was riding his bicycle near the road the airplane impacted, sustained minor injuries when he was struck with small debris and fell off his bicycle. According to the autopsy report issued by the Instituto de Ciencias Forenses, Gobierno de Puerto Rico, the cause of death was thermal injuries, and the manner of death was an accident. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. No tested-for substances were detected. The airplane impacted a residential area front yard including trees, powerlines, and propane fuel tanks. The wreckage remained in a compact area and was oriented on a magnetic heading of 330°. A postaccident fire consumed a majority of the cockpit, fuselage, and portions of both wings. Flight control cable continuity was established from the elevator, rudder, and elevator and rudder trim tabs to the fire damaged cockpit. The elevator trim was found about 1.5°- 2.5° down. The aileron control cables from the cockpit to the center sector were continuous. The right aileron was attached to the remaining wing section and cable continuity was established to the center sector. The left aileron was completely thermally destroyed and unobserved. The left aileron main cables were found attached to the wing sector and continuous to the center sector. Left aileron trim cable continuity was established from the actuator to the control wheel. The chain at both ends was disconnected from their respective sprocket. The flap panels were thermally destroyed and not observed. The measurement of the chain on the actuator corresponded to a flap position of about 10°. The flap cables were continuous to the drive bellcranks and outboard pushrods. The landing gear were found retracted. The flap actuator was measured and corresponded to about a 10° position. The majority of the fuel tanks were thermally damaged. The fuel selector panel was thermally destroyed and the selector valves did not reveal reliable indications. The cockpit, switches, levers, and flight instruments were all severely damaged by fire. Both engines had separated from the airframe and were found a few feet forward of the wings. The engines exhibited impact andpost-impact fire damage. The engine casings did not have any large cracks or holes. The spark plugs and magnetos for each engine remained securely installed. Each engine was equipped with a three-blade propeller. Two of the left engine propeller blades exhibited little to no torsional twisting or bending. One blade exhibited aft bending near its tip, and also had chordwise scratches near the blade root. The right engine propeller blades exhibited varying degrees of chordwise scratching and blade polishing. One blade displayed aft bending, and one blade exhibited forward bending near its tip. The remaining blade exhibited little forward or aft bending. During an examination at the engine manufacturer’s facility, the right engine crankshaft rotated 720° when force was applied to the crankshaft flange. Cylinder compression and valve action movement were observed on all cylinders. Both magneto condensers were damaged by thermal forces and each of the magnetos produced blue spark when a replacement condenser was supplied. The fuel manifold was damaged by thermal forces and was opened for further investigation. Visible corrosion and remains of diaphragm material were present. Below the fuel screen at the fuel inlet within the manifold was a large quantity of debris and foreign material. The left engine crankshaft rotated 720° when force was applied to the crankshaft flange. Cylinder compression was observed on cylinder Nos. 2 through 6. Compression could not be obtained on cylinder No. 1 and when compressed air was applied it leaked past the piston rings. Valve action movement was observed on all cylinders. ## Aircraft - Registration: [N4167G](https://openairdocs.org/aircraft/N4167G), registered now, S/N 402B1214, built 1976 (OpenAirDocs) - Reported make and model: CESSNA 402B (NO SERIES) - Registry model: [Cessna 402B](https://openairdocs.org/model/cessna-402b) (registry code 207590P) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402B1214 - Year built: 1976 - Airframe hours: 12175 - Engines: Continental Motors TSIO-520-E 300 horsepower reciprocating; Continental Motors TSIO-520-E 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: W J Medical Consulting - Registered owner: W J Medical Consulting - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 24, 2024, 2 hours before - Departed: BQN, Aguadilla, PR - Destination: SJU, San Juan, PR - Airport: BQN, Rafael Hernandez, runway 08/26, 11,702 × 200 ft, concrete - Equipment: ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; medical: class 3; seat: left; flight hours: 1,200 total ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 13 knots - Visibility: 10 statute miles - Temperature: 88 °F, dew point 75 °F - Altimeter: 30.01 inHg - Observed at: TJBQ, 1 nm away - METAR: TJBQ 111350Z 07013KT 10SM SCT028 31/24 A3001 ## 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 20240711014689A](https://openairdocs.org/incident/20240711014689A), Jul 11, 2024: Cessna 402B, Aguadilla, PR, Destroyed, 1 fatal. On July 11, 2024, about 0923 atlantic standard time, a Cessna 402B airplane, was destroyed when it was involved in an accident near Rafael Hernandez Airport… ## Other investigations on N4167G (1) 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. - [NTSB CHI78FEX27](https://openairdocs.org/ntsb/CHI78FEX27), Jul 28, 1978: Cessna 402B (N4167G), Indianapolis, IN, destroyed ## Docket (16 files) The files NTSB released with the investigation on May 13, 2026, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=194672. 277 MB in all. - Air traffic control witness statement (item 1, PDF, 2 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19910369&FileExtension=pdf&FileName=ERA24FA301%20ATC%20Statements_Redacted-Rel.pdf - Air traffic control ground tower coms (item 2, PDF, 3 pages, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911144&FileExtension=pdf&FileName=ERA24FA301%20MFR%20Ground%20Tower%20Comms%20Summary-Rel.pdf - Mechanic interview (item 3, PDF, 3 pages, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19910747&FileExtension=pdf&FileName=ERA24FA301%20NTSB%20Memo%20for%20Record%20-%20MFR%20(Mechanic%20BQN)_Redacted-Rel.pdf - Fuel receipt (item 4, PDF, 1 page, 61.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19910980&FileExtension=pdf&FileName=ERA24FA301%20Fuel%20Record_Redacted-Rel.pdf - Pilot logbook endorsements (item 5, PDF, 2 pages, 181 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19910757&FileExtension=pdf&FileName=ERA24FA301%20Pilot%20Log%20Endorsements_Redacted-Rel.pdf - Maintenance records (item 6, PDF, 17 pages, 16.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911170&FileExtension=pdf&FileName=ERA24FA301%20Maintenance%20Record%20Review_Redacted-Rel.pdf - GPS track (plot) (item 7, KML, 208 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19912885&FileExtension=kml&FileName=N4167G%20OpsVue-Rel.kml - Flight track data (item 8, CSV, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911787&FileExtension=csv&FileName=N4167G%20OpsVue-Rel.csv - Investigative photos (item 9, PDF, 6 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19937594&FileExtension=pdf&FileName=ERA24FA301%20Photo%20Array_Redacted-Rel.pdf - Examination summary (item 10, PDF, 9 pages, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19910767&FileExtension=pdf&FileName=ERA24FA301%20Examination%20Summary-Rel.pdf - Engine examination (item 11, PDF, 12 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911344&FileExtension=pdf&FileName=ERA24FA301%20Engine%20Examination-Rel.pdf - POH excerpts (item 12, PDF, 47 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911354&FileExtension=pdf&FileName=ERA24FA301%20POH%20Excerpts-Rel.pdf - Toxicological report (item 13, PDF, 1 page, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911515&FileExtension=pdf&FileName=ERA24FA301%20CAMI_Tox_Redacted-Rel.pdf - Certification of party representatives to an NTSB investigation (item 14, PDF, 10 pages, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911525&FileExtension=pdf&FileName=ERA24FA301%20Combined%20Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 3 pages, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19911482&FileExtension=pdf&FileName=ERA24FA301%20Signed%20Wreckage%20Release_Redacted-Rel.pdf - Video file (item 16, MOV, 993 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19910666&FileExtension=MOV&FileName=POLX8922-Rel.MOV 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.