NYC08LA255

NTSB accident investigation · Cessna 402B · Ocean Ridge, FL · July 22, 2008

Accident · Serious injuriesLimited investigationFinal report
Date
July 22, 2008, 13:50 local (17:50 UTC)
Place
Ocean Ridge, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3990CCessna 402B
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report June 17, 2010
Report
Approved by Office Director
Parties
FAA/FSDO, Teledyne Continental Motors, Cessna Aircraft Company
FAA report
20080722855179A
Case key
68493

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

A partial loss of engine power due to fuel starvation. Contributing to the accident was the pilot’s decision to add only a limited amount of fuel prior to the flight, and the fuel selector valve placards' inaccurate depiction of the airplane fuel tank configuration.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 402B: 3 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 402B: 4 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna 402B: 4 casesAll aircraft: 1,695 casesProbable cause
Engine fuel and control: fuel distributionAircraft › Aircraft power plant · Related operating infoCessna 402B: 1 caseAll aircraft: 55 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot, who was also the former owner of the twin-engine airplane, stated that the purpose of the flight was to reposition the airplane to an airport approximately 22 miles south of the departure airport. Just prior to the flight, he purchased 10 gallons of fuel for each of the two main tanks. The pilot reported that about 5 minutes after takeoff, at an altitude of approximately 1,000 feet, he experienced a "loss of engine power." However, his three separate accounts of the event were inconsistent with respect to which engine had a problem, or the specific nature of the problem. The pilot reported that the airplane started to lose altitude "rapidly," and that he attempted to "wag the wings" in order to "get all the fuel to be useable." The airplane struck a building and terrain approximately 8 miles south of the departure airport. The pilot sustained serious injuries, but there was no fire. Damage to the left engine and propeller was consistent with the engine running at impact, and precluded an attempt to run the left engine in a test cell. Damage to the right engine and propeller was consistent with low or no power at impact. The right engine was subsequently successfully run in a test cell. No evidence of any pre-accident anomalies that could have contributed to the accident was noted with the airframe, engines, or propellers. The fuel selector valve placards did not accurately depict the fuel system configuration. The fuel quantity and its distribution in the tanks, either at the beginning of the flight or at the time of the accident, could not be determined.

Factual narrative

History of flight

On July 22, 2008, about 1350 eastern daylight time, a Cessna 402B, N3990C, was substantially damaged when it impacted a building and the ground in Ocean Ridge, Florida. The certificated commercial pilot, the sole occupant, was seriously injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan was filed.

The pilot stated that the purpose of the flight was to reposition the airplane from Palm Beach County Park Airport (LNA), West Palm Beach, Florida, to Pompano Beach Airpark (PMP), Pompano Beach, Florida, for future maintenance. PMP was located approximately 22 miles south of LNA. Statements provided by line personnel at LNA indicated that the pilot purchased 20 gallons of fuel just prior to the accident flight, and that the fuel was dispensed evenly into the two tip tanks of the accident airplane.

In interviews with Federal Aviation Administration (FAA) inspectors, the pilot stated that he took off from LNA and kept the airplane’s landing gear extended for the flight. He was aware of a problem with the landing gear, and thought that if he retracted the gear, he would not be able to successfully re-extend it for landing. After departing LNA, the pilot flew south over the Atlantic Intracoastal Waterway at an altitude of between 800 and 1,000 feet, enroute to PMP.

The pilot reported that about 5 minutes into the flight, he experienced a "loss of engine power." In one interview with FAA inspectors, he stated that he had problems with the left engine, but during a subsequent interview, he stated that the right engine malfunctioned. In a written statement that the pilot provided to the Ocean Ridge Police Department, dated 6 days after the accident, the pilot did not specify which engine malfunctioned. Instead, he reported only that he attempted to "identify and verify which engine(s) were causing trouble." In the same statement, the pilot reported that he started to lose altitude "rapidly," and attempted to "wag the wings" side to side in order to "get all the fuel to be useable." He stated that he "must have blanked out," because the last thing he remembered about the accident was seeing the top of the town hall building just prior to impact. The airplane struck the Ocean Ridge town hall building, located approximately 8 miles south of LNA.

Several witnesses reported that the airplane was traveling north to south, was flying slowly with the landing gear extended, and that the wings were "rocking." Many witnesses also reported that the engines were operating.

Personnel information

According to FAA records, the pilot, age 50, held a commercial pilot certificate with airplane single-engine land, multi-engine land, and instrument ratings. In 2004, the pilot reported that he had 1,560 total hours of flight experience. His most recent FAA second-class medical certificate was issued in February, 2008. Despite multiple requests, the pilot did not provide his personal logbook or other information requested by National Transportation Safety Board (NTSB).

Aircraft information

The accident airplane was an all-metal, twin-engine, low-wing monoplane, with retractable landing gear. According to FAA records, the airplane was manufactured in 1975. It was powered by two Continental TSIO-520 series engines, each equipped with a three-bladed, constant-speed propeller. The airplane was previously owned by the pilot, but he sold it to another individual in September 2007, and the FAA airplane registration form was issued to that individual in January, 2008. The individual who owned the airplane at the time of the accident did not hold any pilot certificates.

Meteorological information

The 1347 surface weather observation at an airport located 6 miles south of the accident site included winds from 160 degrees at 8 knots, visibility 10 miles, scattered clouds at 2,500 feet, temperature 30 degrees C, dew point 25 degrees C, and an altimeter setting of 30.08 inches of mercury.

Communications

No air traffic control voice communications or ground radar tracking data regarding this flight were able to be located.

Wreckage and impact information

After it struck the building, most of the airplane came to rest inverted on the ground, against a concrete utility pole. There was no post-impact fire. The left wing was separated from the fuselage, and the left tip tank was separated from the left wing. The right wing and fuselage were on opposite sides of a concrete utility pole, and were structurally separated from one another, but remained attached by wires and control cables. The outboard section of the right wing, including the tip tank, was separated from the inboard wing. The fuselage was fractured just aft of the pilots' seats. The horizontal stabilizer was separated from the fuselage. The left engine was found approximately 25 feet from the main wreckage, and the left propeller was separated from the left engine. The right engine remained attached to the airframe, and the right propeller remained attached to the right engine. All three landing gear were found in their respective down and locked positions. The left landing gear, left engine nacelle and a portion of the left inboard wing were found on the roof of the building.

Additional information

Maintenance Records Examination

A review of the airframe and engine maintenance records that dated back to February 2002 revealed that only three annual inspections were recorded over the 6 year period.

An annual inspection was completed in February 2002, when the airplane had accrued a total time (TT) in service of 7,135 hours. The corresponding Hobbs meter entry in each engine logbook (only one Hobbs meter was installed in the airplane) indicated that each engine had accrued 856.2 hours since major overhaul (SMOH). The next annual inspection was completed in March 2004, when the airplane had accrued a TT of 7,145.8 hours, and the Hobbs meter reading was recorded as 866.4 hours. The most recent annual inspection was completed in March 2006, when the airplane had accrued a TT of 7,221.9 hours, and the Hobbs meter reading was recorded as 942.5 hours. The March 2006 annual inspection was the most recent entry in the airframe, engine and propeller maintenance records.

Detailed Airframe Examinations

Recovery personnel had separated the fuselage into two pieces, and they had also detached the right wing. On August 5, 2008, personnel from the FAA, Cessna Aircraft, and Teledyne Continental Motors (TCM) and the NTSB examined the airplane at the recovery facility in Boynton Beach, Florida. On March 10, 2010, NTSB personnel re-examined selected portions of the fuel system.

The cockpit area and instrument panel were relatively intact, with some crush and deformation damage. The cockpit throttle, propeller, and mixture controls were all found at or near their full-forward positions. The two magneto switches for the left engine, and the left magneto switch for the right engine, were in their respective "On" positions. The right magneto switch for the right engine was in the "Off" position. The "L Alt" and "Batt" master switches were in their respective "On" positions, and the "R Alt" master switch was in the "Off" position. The two guarded emergency power switches were found in different positions. The "Alt Field" cover was down (stowed), while the "Avionics Bus" cover was up, with its switch in the up/forward position. Numerous circuit breakers on the left side circuit breaker panel, including "Turn & Bank 1, L Fuel Pump, Comm 3, ADF, DME, Audio Amp, Xpndr 1, and Radar" were in the activated (circuit disabled) position. The Hobbs hour meter in the cockpit indicated 969.1 hours, and a placard below it stated "Total Time Add 6279.4 Hrs."

The landing gear handle was found in the gear-retracted position, but the positions or con

Aircraft

Registration
N3990C
Reported as
Cessna 402B
Category
Airplane
Serial number
402B0857
Airframe hours
7,222
Engines
Teledyne Continental TSIO-520, 300 horsepower, reciprocatingTeledyne Continental TSIO-520, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Laurent M. Gillot
Registered owner
Jean Bayardelle
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 27, 2006 · 27 hours before
Departed
LNA · Lantana, FL
Destination
PMP · Pompano Beach, FL

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
51
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 10, 2008
Seat
Left
Flight hours
1,565 total

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 77 °F
Altimeter
30.07 inHg
Observed at
BCT, 6 nm away

Docket · 12

The files NTSB released with the investigation on April 6, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.9 MB in all.

FAA reports on this event · 1

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