LAX93GA053

NTSB accident investigation · Cessna 404 · Tucson, AZ · November 27, 1992

Accident · No injuriesFinal report
Date
November 26, 1992, 19:15 local (Nov 27, 1992, 02:15 UTC)
Place
Tucson, AZ
Injuries
1 uninjured
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N5429JCessna 404
Weather
Visual (VMC) · Night/dark
Status
Completed · report August 26, 1993
Report
Approved by Office Director
Case key
27835

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inflight decision to deviate from the airplane's engine manual and the pilot's operating handbook by maintaining the fuel mixture at full rich throughout the mission and rapidly descending the airplane which resulted in both engine's losing total power. Factors in this accident were 1) the pilot not following the emergency procedure for both engines failing as outlined in the pilot's operating handbook, and 2) the pilot not performing a flare during the landing sequence which resulted in the airplane colliding with the terrain.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalDescent - normal
2 engines
In-flight planning/decision - poorPilot in commandCause
Procedures/directives - not followedPilot in commandCause
Forced landingDescent - emergency
In flight collision with terrain/waterDescent - emergency
Emergency procedure - not followedPilot in commandFactor
Flare - not performedPilot in commandFactor
Terrain condition - ground

Analysis

During a 2 hour and 40 minute training mission, the pilot maintained a low power setting with the fuel mix at full rich. After the mission, the pilot climbed the airplane to 9,000 feet AGL to clear obstacles between his location and his destination. During the descent, the pilot said he reduced power more rapidly than usual and descended faster than normal at about 180 KIAS. About 800 to 1,000 feet AGL, in the traffic pattern, the pilot applied power. Both engines lost total power. He set up an 85 KIAS glide; competed emergency procedures; and retracted the landing gear. The engines did not re start. He did not feather the propellers. He extended the landing gear prior to touchdown. The pilot said he did not flare the airplane during landing which resulted in the airplane colliding with the ground. The engine manual and the POH recommend adjusting the fuel mixture for cruise. An engine manual note states long descents at low power should be avoided because the engines may cool excessively and may not accelerate satisfactorily when power is re applied. The POH recommends feathering propellers and gliding at 120 KIAS for dual engine failure. Soot was noted on all spark plugs during engine exam. Both engines started and ran normally from idle to full acceleration during the exam.

Aircraft

Registration
N5429J
Reported as
Cessna 404
Category
Airplane
Serial number
4040107
Airframe hours
4,011
Engine
Continental GSTIO-520-M2B, 375 horsepower, reciprocating
Damage
Destroyed
Flight
Public aircraft · Part 91
Operator
U. S. Customs Service, doing business as Tucson Air Branch
Registered owner
United States Customs Service
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 26, 1992 · 38 hours before
Departed
DMA
Destination
DMA
Flight plan
Company VFR
Airport
DMA · Davis Monthan Afb, runway 12, 13,645 × 200 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
4,981 total · 685 in this make and model · 4,154 as pilot in command · 49 in the last 90 days · 22 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
40° at 6 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 12 °F
Altimeter
30.00 inHg
Observed at
TUS, 4 nm away