# NTSB MIA03FA135: Cessna 414, N749AA, N. Fort Myers, FL, June 26, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 26, 2003, 12:51 local (16:51 UTC) - Place: N. Fort Myers, FL - Coordinates: 26.744722, -81.934997 - Nearby events: https://openairdocs.org/map.md?lat=26.7447&lon=-81.9350&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious, 1 minor - Status: Completed, report April 25, 2006 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Shadin Company, Inc., Cessna Aircraft Company, McCauley Propeller Systems, FAA Flight Standards District Office - NTSB case key (mKey): 57356 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA03FA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57356/pdf - Page: https://openairdocs.org/ntsb/MIA03FA135 ## Probable cause The failure of the pilot to maintain airspeed (Vs) following a total loss of engine power from the right engine due to fuel starvation, resulting in an inadvertent stall, uncontrolled descent, and in-flight collision with trees and terrain. Factors in the accident was the failure pilot to feather the right propeller following the total loss of engine power, and his lack of total experience in the accident make/model of aircraft. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - vfr pattern - base turn - aircraft preflight - inadequate, pilot in command - 1 engine - fluid,fuel - starvation - emergency procedure - not performed, pilot in command (contributing factor) - Loss of control - in flight, maneuvering - airspeed(vs) - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with object, descent - uncontrolled - object - tree(s) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot reported visually checking the main fuel tanks during his preflight inspection of the airplane and later reported there was enough fuel for the intended flight which would be less than 1 hour, plus a 45-minute reserve amount of fuel. He estimated the fuel level in the main fuel tanks was 2-3 inches from the top. He also reported that before the accident flight he had never flown the accident make and model airplane, and that he had not had any flight training in the airplane. The passengers were boarded, the flight departed and climbed to between 4,500 and 6,500 feet msl. He leaned the mixture during cruise, and the flight continued. He began descending when the flight was 12 miles from the destination airport, and he performed the pre landing checks when the flight was 3 miles from the destination airport. The flight entered left downwind where he lowered the landing gear and turned on the fuel pumps. When abeam the landing point he reduced power, lowered the flaps 10 degrees, and turned onto base leg. During the base leg while rolling out of the turn and flying at 600 feet, "the right engine suddenly came to a stop...." He banked to the left to maintain zero sideslip, pushed the mixture, propeller, and throttle controls full forward, and identified the right engine had failed. He reportedly pulled the right propeller control to the feather position but during the postaccident investigation, the right propeller blades were not in the feather position and there was no evidence of preimpact failure or malfunction of the propeller. The pilot further reported that while pulling the right propeller control to the feather position, the airplane, "began to yaw right and simultaneously bank right...." He moved the left throttle control to idle, and they were on the ground in a span of 6 seconds from the time the right engine quit. No fuel leakage was noted at the scene, and no fuel contamination was noted in a nearby pond. Additionally, only residual fuel was noted in the fuel lines in each engine compartment. A total of 4.0 and 1.5 gallons of fuel were drained from the left and right auxiliary fuel tanks, respectively. No evidence of preimpact flight control failure or malfunction was noted. Neither propeller was at or near the feather range at the time of impact. Both engines were removed from the airplane, placed on a test stand with a "club" propeller, and both engines were noted to operate normally during the engine run. Examination of the right seat in the third row of the airplane revealed the seat frame was bent down on the left side, and all seat feet were in position but distorted; no fracture of the seat feet were noted. Examination of the seat of the passenger who sustained minor injuries (left seat in the third row) revealed the seatpan was compressed down, and the lapbelt was unbuckled. The inboard arm rest was bent inward, and the outboard arm rest was bent outward. The seat frame indicated displacement to the left. The seat back was twisted counter clockwise, and the left forward seat foot was in place. The seat and attach structure was certificated for a maximum forward g loading of 9 g's, and a maximum sideward g loading of 1.5 g's. This does not include a 1.33 margin of safety factor. The seat and attach structure was tested to ultimate loads in a combined forward, sideward, and upward directions in accordance with CAR 3.390-2. The same loads were also applied in a downward direction by itself. The empennage was separated just aft of the aft pressure bulkhead but remained secured by flight control cables. According to personnel from the airplane manufacturer, the tested load (150 percent limit) for the empennage in negative shear translates to 14.0 g loading. Based on Cessna Engineering rough calculations, they believe the empennage is capable of sustaining an additional 30 percent beyond what it was tested to, or an estimated 18.2 g's in negative shear loading. ## Factual narrative HISTORY OF FLIGHT On June 26, 2003, about 1251 eastern daylight time, a Cessna 414, N749AA, registered to Osprey Air Services, Inc., experienced an in-flight loss of control and collided with trees then the ground near North Fort Myers, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal flight from Palm Beach County Park Airport (KLNA), West Palm Beach, Florida, to Pine Shadows Airpark, Fort Myers, Florida. The airplane was substantially damaged and the commercial-rated pilot sustained serious injuries. A pilot-rated passenger seated in the copilot's seat and another passenger in the cabin were fatally injured. The remaining passenger sustained minor injuries. The flight originated about 1213, from Palm Beach County Park Airport. According to an NTSB prepared transcription of communications from an uncertified copy of the voice tape from Fort Myers Air Traffic Control Tower, at an undetermined time, the pilot contacted the facility and was advised by the controller to remain clear of "Class Charlie Airspace." A position relief briefing was conducted and the controller established contact with the pilot who advised that the flight was over Lake Okeechobee inbound to " Pine Shadows Airpark", and requesting VFR flight following. The controller provided a discrete transponder code and altimeter setting. The pilot repeated the altimeter setting and advised the controller that he would report when the destination airport was in sight. The flight was radar identified, and the flight continued. At an undetermined time the pilot advised the controller that the destination airport was in sight; the controller advised the pilot that radar service was terminated and frequency change was approved. The pilot acknowledged that transmission. There were no further recorded transmissions from the pilot. The pilot later stated in writing that he performed a "thorough" preflight inspection of the airplane using a checklist. He "examined the fuel and calculated that we would have at least 45 minutes of reserve fuel after we landed", and he checked both main fuel tanks. He reported twice checking the fuel level in both main fuel tanks and reported the level in both tanks was 2-3 inches from the top. He estimated the flight duration to be less than 1 hour, and he planned on fueling the airplane at the destination airport, so he did not fill the auxiliary or engine nacelle tanks. The passengers were boarded, and both engines were started; the right engine took a little more time to start than the left. He "checked that all the pressures and temperatures were within proper limits and the magnetos on each engine were operating properly." The pilot stated that the flight departed to the east from KLNA, and after takeoff initially climbed to 2,500 feet mean sea level (msl), then climbed to between 4,500 and 6,500 feet msl. During cruise flight he leaned the fuel/air ratio for each engine and completed the cruise checklist items. The flight continued and he began to descend when the destination airport was in sight, which was when the flight was 12 miles away. When the flight was 3 miles from the destination airport he performed the pre landing checks and noticed, "the fuel gauges indicated 15 gallons/90 lbs. of fuel remaining in the left main tank and 18 gallons/108 lbs. in the right main fuel tank." Less than 2 minutes later he entered left downwind for landing to the east at the destination airport and went through the "pre landing GUMPS checks." He lowered the landing gear, turned on the fuel pumps for both engines, enrichened the fuel/air ratio, verified that the gear was down and locked, and that everyone had their seatbelts on. While flying at an airspeed 25 knots above the manufacturers recommended final approach speed and when abeam the touchdown point, he reduced power and lowered the flaps 10 degrees. He turned onto base leg, and while rolling out of the turn he stated, "the right engine suddenly came to a stop, and I banked to the left maintaining a zero sideslip configuration and directional control." He pushed the mixture, propeller, and throttle controls forward in that order, and identified that the right engine had failed. He pulled the right propeller control to the feather position, and while doing so the airplane, "began to yaw right and simultaneously bank right. I reached for the throttle on the left engine and pulled it [to] idle, attempted to maintain control of the aircraft and accomplish an emergency landing in the safest area I could find." He also stated that the right engine quit while flying at 600 feet and less than 6 seconds later, "we were on the ground." A witnesses located approximately 3/4 nautical mile northeast of the crash site reported seeing the airplane banking to the left, which increased to an inverted position as well as being in a nose low attitude, nearly vertical. The airplane was then observed to roll to the right while remaining in the nose low attitude. The witness then lost sight of the airplane due to obstructions. Another witness located approximately .15 nautical mile southeast of the accident site reported seeing the airplane flying westbound with decreasing engine sound; no smoke or fire was observed trailing the airplane. The airplane was observed to spin to the right 4 times in a tight turn; the witness then lost sight due to obstructions. The passenger who sustained minor injuries reported to sheriff's office personnel that prior to the accident, the landing gear was extended and he heard a buzzing sound immediately before the airplane entered a spin. He was not sure how many times the airplane spun. PERSONNEL INFORMATION The pilot (left seat occupant) is the holder of a commercial pilot certificate with ratings airplane single engine land, airplane multi-engine land, and instrument airplane. He was also the holder of a certified flight instructor certificate with airplane single engine, and instrument airplane ratings. The instrument rating was added on May 30, 2003, which was the date of his last flight review or equivalent required by 14 CFR Part 61.56. He was issued a first class medical certificate on December 6, 2002, with no limitations. A review of the pilot prepared NTSB "Pilot/Operator Aircraft Accident Report" form revealed he listed a total time of 972 hours, with 0 hours in make and model and 38 hours total multi-engine time. In the last 90 days he listed a total time of 266 hours, with 3 hours in multi-engine airplanes and the remainder in single engine airplanes. During the last 30 days, he listed a total time of 90 hours, and during the last 24 hours he listed a total time of 6 hours, with 3 of the 6 hours in multi-engine airplanes. A review of the pilots' pilot logbook revealed he was signed off by a certified flight instructor to operate a pressurized airplane capable of operating at high altitudes in accordance with 14 CFR Part 61.31(g), on May 31, 2003. The flight was conducted in a Beech 200 airplane; the flight duration was recorded to be 1.3 hours. According to FAA records, the right seat occupant was the holder of a private pilot certificate with airplane single engine land rating. He was issued a third class medical certificate on March 13, 2003, with the limitation that he wear corrective lenses and possess glasses for near/intermediate vision. He listed a total time of 400 hours on the application for the last medical certificate. AIRCRAFT INFORMATION The airplane was manufactured by Cessna Aircraft Company in 1970, as model 414, and designated serial number 414-0049. It was type certificated in the normal category in accordance with Civil Aeronautics Regulation (CAR) 3, and equipped with two Teledyne Continental Motors TSIO-520-J engines rated at 310 horsepower. The airplane was also equipped with two McCauley, constant speed, manual feat ## Aircraft - Registration: [N749AA](https://openairdocs.org/deregistered/N749AA-2017-04-04), registration cancelled 2017-04-04, S/N 414-0049, built 1970 (OpenAirDocs) - Reported make and model: Cessna 414 - Registry model: [Cessna 414](https://openairdocs.org/model/cessna-414) (registry code 2075908) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 414-0049 - Airframe hours: 1710.1 - Engines: Continental TSIO-520-J 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: John E. Nowicki Jr. - Registered owner: Osprey Air Services, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2003 - Departed: KLNA, West Palm Beach, FL - Destination: 94FL, Fort Myers, FL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; injuries: serious; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 1, 2003; seat: left; flight hours: 972 total, 0 in this make and model, 853 as pilot in command, 266 in the last 90 days, 90 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 72 °F - Altimeter: 30.04 inHg - Observed at: KFMY ## 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 20030626018209A](https://openairdocs.org/incident/20030626018209A), Jun 26, 2003: Cessna 414, Ft. Myers, FL, Destroyed, 2 fatal. (-23) On June 26, 2003, at 1251 EST, a Cessna 414, N749AA, operating as a 14 CFR part 91 personal flight, experienced an in-flight loss of control and collided… 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.