NYC99LA200

NTSB accident investigation · Cessna 208 · Hillsborough, NH · August 13, 1999

Accident · Minor injuriesLimited investigationFinal report
Date
August 13, 1999, 13:11 local (17:11 UTC)
Place
Hillsborough, NH
Injuries
1 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N193GECessna 208
Weather
Visual (VMC) · Day
Status
Completed · report June 22, 2000
Report
Approved by Office Director
FAA report
19990813012049A
Case key
47095

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

an inadequate auxiliary fuel tank installation which resulted in a leak of undetermined origin.

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.

Airframe/component/system failure/malfunctionClimb
Fuel system,tank - leakCause
Maintenance,installation - inadequateOther maintenance personnelCause
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - hidden obstruction(s)
Terrain condition - ditch

Analysis

With an auxiliary fuel tank system installed, the pilot filled the tanks and departed. A few minutes later, he noticed fuel on the floor of the cabin, and tried to reach an airport. However, the fuel fumes were so strong he elected to land in an open field. After touchdown, the airplane passed through a ditch the pilot had not observed from the air. The nose landing gear collapsed and the airplane nosed over. An airborne witness reported the pilot exited the airplane after about 5 minutes, and about 5 minutes later, the airplane caught fire and burned. The post-crash fire consumed the cabin. In an interview, the pilot reported that he had not initiated use of the auxiliary fuel tank system when the accident occurred. He also reported he could not see where the fuel was coming from. The investigation revealed the tank installation did not match the FAA Form 337, the instructions for use of the ferry tank system were inadequate, and the pilot had reported that the auxiliary fuel pumps were secured to a board which was not secured to the airplane.

Factual narrative

On August 13, 1999, at 1311 eastern daylight time, a Cessna 208, N193GE, was destroyed during a precautionary landing near Hillsborough, New Hampshire. The certificated airline transport pilot received minor injuries. Visual meteorological conditions prevailed for the ferry flight which departed from Manchester, New Hampshire (MHT), and was destined for Denver, Colorado (DEN). The flight was operated on an instrument flight rules flight plan under 14 CFR Part 91.

The pilot reported he flew the airplane to Bangor, Maine, on August 11, 1999, for the installation of two auxiliary fuel tanks. The installation took place on August 12 and 13, and the pilot flew the airplane to Manchester, Hampshire (MHT) where the auxiliary fuel tanks were filled. The Federal Aviation Administration (FAA), Portland Flight Standards District Office had issued a special flight permit for the overweight operation of the airplane.

At MHT, the airplane was serviced with 654 gallons of Jet-A. The wing tanks were filled, and the auxiliary fuel tanks (205 gallons each) were serviced with 190 gallons each, which brought them to within 1 inch of the top. The pilot reported that the gross weight of the airplane was about 10,000 pounds.

The takeoff and initial climb were without incident. As the airplane passed through about 800 to 900 feet, the pilot smelled turbine fuel. He stopped the climb and attempted to locate the source of the fumes. From his seat in the cockpit, he could not identify the source of the fumes. He requested radar vectors to the closest airport and initiated a descent. He then noticed about 1 inch of standing fuel on the floor of the cabin, and turned off the radios.

During the descent, the amount of fuel in the cockpit area continued to increase, so the pilot elected to land in an open field rather than continue toward the airport. He reported that due to fuel fumes and raw fuel in the cockpit, his vision was blurred, his eyes burned, and he had difficulty breathing. He positioned the airplane for landing into the wind. On final approach, the fuel was up over his ankles and his sectional charts were floating on top of the fuel.

After touchdown, he applied maximum reverse thrust and brakes. During the ground roll, at a speed of about 40 knots, he observed a ditch ahead of him. He had no further memory of events until he was being treated by paramedics.

A nearby airplane observed the landing and reported that the airplane nosed over during the landing roll. After about 5 minutes, the pilot exited the airplane and crawled away. About 5 minutes later, the airplane started to burn. Medical personnel arrived about 15 minutes after the accident.

An inspector from the FAA reported that the airplane traveled about 400 feet on the ground prior to encountering a ditch which measured about 60 feet wide and 3 feet deep. The airplane crossed the ditch, and continued for about another 120 feet and came to rest. The nose landing gear had separated from the airplane. The airplane was consumed by fire except for the outboard wing panels and empennage.

Documents from the FAA and interviews with the pilot revealed the two tanks were mounted in the cabin laterally, and secured to the floor with tie-down straps. The takeoffs for the fuel lines were on the back side of the fuel tanks and not visible to the pilot. The two tanks fed into a common manifold, which was used to replenish the right wing fuel tank. The engine could not be fed directly from the auxiliary tanks. The pilot reported that he had not actuated the auxiliary tank system on the flight.

Examination of the supporting documents for the tank installation, furnished by the facility that performed the work, and interviews with the pilot, revealed the following; the fuel tanks were installed laterally; however, the FAA Form 337 showed the fuel tanks installed longitudinally; the instructions issued to the pilot for the use of the auxiliary tank system did not cover all contingencies, or limitations; the pilot reported that the 3 auxiliary fuel pumps used to transfer fuel from the auxiliary tanks to the right wing tank were secured to a platform. However, the platform was not secured to the airplane.

These items were discussed with the FAA Principle Maintenance Inspector (PMI) who had oversight authority for the facility that performed the auxiliary tank installation. The PMI reported that the facility has subsequently changed their procedures.

Aircraft

Registration
N193GE
Reported as
Cessna 208
Category
Airplane
Serial number
20800193
Airframe hours
6,132
Engine
P&W PT6-114A, 600 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Ferry · Part 91
Operator
Ram Aeronautical
Registered owner
Greystoke Engineering Inc.
Airworthiness certificate
Special, Special flight (Special)
Last inspection
AAIP · June 8, 1999 · 79 hours before
Departed
MHT · Manchester, NH
Destination
DEN · Denver, CO
Flight plan
IFR

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
47
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine sea, Multi-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
10,530 total · 3,000 in this make and model · 10,458 as pilot in command · 168 in the last 90 days · 22 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 8 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
MHT, 22 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.