MIA89FA065

NTSB accident investigation · Britten-Norman BN-2A · Carolina, PR · January 16, 1989

Accident · No injuriesField investigationFinal report
Date
January 16, 1989, 18:14 local (22:14 UTC)
Place
Carolina, PR
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N457SABritten-Norman BN-2A
Weather
Visual (VMC) · Dusk
Status
Completed · report January 11, 1990
Report
Approved by Office Director
FAA report
19890116000539A
Case key
32271

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

Fuel exhaustion and the failure of the pilot to insure that the proper fuel load was placed on the aircraft for the flight. Contributing factors included the improper refueling of the aircraft, improper initial training of the refueler and the crop, which caused substantial damage to the aircraft.

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
Refueling - improperFbo personnelFactor
Improper initial trainingFbo personnelFactor
Aircraft preflight - improperPilot in commandCause
Procedures/directives - not followedPilot in commandCause
Fluid,fuel - exhaustionCause
Forced landingDescent
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - cropFactor
Terrain condition - wet

Analysis

The plt ordered 42 gallons of fuel to be added to the acft which would bring the total fuel load to 60 gallons. The lineman added 4.2 gallons bringing the total fuel load to 22.2 gallons. The plt did not verify the fuel load prior to departure. The acft was flown from san juan to vieques in which 12 gallons were burned. No fuel was added and the plt again did not verify his fuel load. The flt departed vieques en route back to san juan with 10.2 gallons of fuel. On descent into san juan both engines failed and a forced landing was made in a sugar cane field. After rolling about 100 yds the left ldg gr collapsed. Post crash examination of the acft revealed it contained 36 ounces of fuel with no evidence of leakage. The engines were operated to full power with no evidence of mechanical failure or malfunction after the accident. The lineman had been hired as a part-time employee on 1/2/89. He stated he was working only his fifth day and that he had no formal refueling trng.

Aircraft

Registration
N457SA
Reported as
Britten-Norman BN-2A
Category
Airplane
Serial number
27
Airframe hours
9,938
Engine
Lycoming O-540-E4C5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Registered owner
Vieques Air Link, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 12, 1989 · 9 hours before
Departed
VQS · Vieques, PR
Destination
SIG · San Juan, PR
Flight plan
VFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
7,200 total · 2,100 in this make and model · 5,200 as pilot in command · 150 in the last 90 days · 60 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
120° at 5 knots
Visibility
12 statute miles
Lowest ceiling
9,000 ft broken
Temperature
73 °F, dew point 70 °F
Altimeter
30.00 inHg
Observed at
SJU, 3 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.