# NTSB MIA89FA065: Britten-Norman BN-2A, N457SA, Carolina, PR, January 16, 1989

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Field investigation · Final report
- Date: January 16, 1989, 18:14 local (22:14 UTC)
- Place: Carolina, PR
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 6 uninjured
- Status: Completed, report January 11, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 32271
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA89FA065
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32271/pdf
- Page: https://openairdocs.org/ntsb/MIA89FA065

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - nonmechanical, descent - normal
  - refueling - improper, fbo personnel (contributing factor)
  - improper initial training, fbo personnel (contributing factor)
  - aircraft preflight - improper, pilot in command (cause)
  - procedures/directives - not followed, pilot in command (cause)
  - fluid,fuel - exhaustion (cause)
- Forced landing, descent
- On ground/water encounter with terrain/water, landing - roll
  - terrain condition - crop (contributing factor)
  - 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](https://openairdocs.org/deregistered/N457SA-1991-02-07), registration cancelled 1991-02-07, S/N 27 (OpenAirDocs)
- Reported make and model: BRITTEN-NORMAN BN-2A
- Registry model: [Britten-Norman BN-2A](https://openairdocs.org/model/britten-norman-bn-2a) (registry code 1520204) (OpenAirDocs)
- Category: Airplane
- Serial number: 27
- Airframe hours: 9938
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 35; 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 (OpenAirDocs).

- [Accident 19890116000539A](https://openairdocs.org/incident/19890116000539A), Jan 16, 1989: Bnorm BN2A, Carolina, Puerto Rico, Substantial damage. Ran out of fuel and crash landed in a cane field. Ordered fuel but failed to check. Lineman read 4.2 as 42 gallons.

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.

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