# NTSB NYC08LA255: Cessna 402B, N3990C, Ocean Ridge, FL, July 22, 2008 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 22, 2008, 13:50 local (17:50 UTC) - Place: Ocean Ridge, FL - Coordinates: 26.518333, -80.041664 - Nearby events: https://openairdocs.org/map.md?lat=26.5183&lon=-80.0417&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report June 17, 2010 - Report: Approved by Office Director - Parties: FAA/FSDO, Teledyne Continental Motors, Cessna Aircraft Company - NTSB case key (mKey): 68493 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08LA255 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68493/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68493 - Page: https://openairdocs.org/ntsb/NYC08LA255 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 402B, 3 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=207590P), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 402B, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=207590P), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cessna 402B, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=207590P), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Related operating info (probable cause); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=207590P), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=207590P), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Enroute-cruise: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Cessna 402B, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=207590P), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 402B, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=207590P), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Enroute-cruise: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 402B, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=207590P), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 402B, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=207590P), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N3990C-2018-01-18), registration cancelled 2018-01-18, S/N 402B0857, built 1975 (OpenAirDocs) - Reported make and model: CESSNA 402B - Registry model: [Cessna 402B](https://openairdocs.org/model/cessna-402b) (registry code 207590P) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402B0857 - Airframe hours: 7222 - Engines: Teledyne Continental TSIO-520 300 horsepower reciprocating; Teledyne 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: serious; 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 ## 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 20080722855179A](https://openairdocs.org/incident/20080722855179A), Jul 22, 2008: Cessna 402B, Ocean Ridge, FL, Destroyed. (-23) Aircraft was fueled at lantana airport at approximately 1230 on July 22, 2008. After having 10 gallons added to each wing tip pilot, [privacy data… ## Docket (12 files) The files NTSB released with the investigation on April 6, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68493. 12.9 MB in all. - Pilot Statement to FAA (item 1, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327161&FileExtension=.PDF&FileName=Pilot%20Statement%20to%20FAA-Redacted.PDF - Pilot Written Statement (item 2, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327162&FileExtension=.PDF&FileName=Pilot%20Written%20Statement-Redacted.PDF - Fueling Statements (item 3, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327164&FileExtension=.PDF&FileName=Fueling%20Statements-Redacted.PDF - Witness Statements (item 4, .PDF, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327163&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - FAA Wreckage Diagram (item 5, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327165&FileExtension=.PDF&FileName=FAA%20Wreckage%20Diagram-Master.PDF - Compiled Photographs (item 6, .PDF, 11.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327186&FileExtension=.PDF&FileName=Compiled%20Photographs-Master.PDF - Fuel System Information (item 7, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327195&FileExtension=.PDF&FileName=Fuel%20System%20Information-Master.PDF - Maintenance Records Excerpts (item 8, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327324&FileExtension=.PDF&FileName=Maintenance%20Records%20Excerpts-Redacted.PDF - POH Excerpts (item 9, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327194&FileExtension=.PDF&FileName=POH%20Excerpts-Master.PDF - Left Engine Exam Excerpts (item 10, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327192&FileExtension=.PDF&FileName=Left%20Engine%20Exam%20Excerpts-Redacted.PDF - Right Engine Exam Excerpts (item 11, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327193&FileExtension=.PDF&FileName=Right%20Engine%20Exam%20Excerpts-Master.PDF - Cessna Responses to NTSB Airplane Questions (item 12, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327768&FileExtension=.PDF&FileName=Cessna%20Responses%20to%20NTSB%20Airplane%20Questions-Master.PDF 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.