WPR21LA313

NTSB accident investigation · Cessna 425 · Helena, MT · August 11, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 11, 2021, 09:00 local (15:00 UTC)
Place
Helena, MT · rural residential area
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N783MBCessna 425
Defining event
Emergency descent: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Textron - Cessna
FAA report
20210811013679A
Case key
103681

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 flameout of both engines due to fuel starvation for reasons that could not be determined due to the airplane’s damage.

Findings · 1

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.

Power plantAircraft › Aircraft power plant · Unknown/Not determinedCessna 425: 1 caseAll aircraft: 198 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 pilot stated that on the morning of the accident he filled both wing fuel tanks to full. After takeoff, he climbed to his planned cruise altitude of 24,000 ft mean sea level (msl). While en route to his destination, the pilot reported that the left engine experienced a flame-out. The pilot opted to divert from the originally planned destination and descended. When the airplane was about 7,900 ft msl, the pilot reported that the right engine experienced a loss of power and that he was not going to be able to make it to the airport. Shortly thereafter, the airplane collided with trees and the airplane came to rest with the right wing and empennage severed from the fuselage. There was fuel in the wing tanks at the time of the impact. Postaccident examination of the wreckage did not reveal any anomalies. A partial amount of fuel was found in both of the filter bowls, but it is unknown if fuel was able to reach the engines. A complete examination of the fuel system could not be completed due to the damage incurred to the airplane at impact. Both engines flaming out within a short time of one another is likely indicative of a fuel supply or delivery issue; however, the nature of the problem could not be identified during postaccident examination.

Factual narrative

On August 11, 2021, about 0900 mountain daylight time, a Cessna 425 Conquest 1, N783MB, sustained substantial damage when it was involved in an accident near Helena, Montana. The pilot and two passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The pilot stated that on the morning of the accident he refueled the airplane to full wing tanks by adding an additional 207 gallons of Jet A. Shortly thereafter, he departed from his home airport in Faribault, Minnesota and continued to his destination at a cruise altitude of 24,000 ft mean sea level. Air Traffic Control transmissions and automatic dependent surveillance-broadcast data indicate that, while en route at 0847:35, the pilot reported to an air traffic controller that the airplane had an engine [left engine] flame-out and requested a descent. The pilot opted to divert from the originally planned destination and contacted Helena approach control. He stated that the airplane was 16 miles from Helena and descending through 19,000 ft, advising the controller that he may need to lose altitude to land on runway 27. The controller responded that the pilot could maneuver north of the airport to align with the right base leg of the traffic pattern to the runway. At 0852:59 the pilot reported to the air traffic controller that he had an hour and a half of fuel on board and about 3 minutes later the airplane made a right turn to the north. At 0857:15, with the airplane about 7,900 ft msl, the pilot reported that the right engine experienced a loss of power (see Figure 1 below). At 0859:02, the pilot reported the airplane was going to collide with trees. The airplane came to rest with the right wing and empennage severed from the fuselage. There was fuel onboard the airplane at the time of impact, the quantity is unknown due to the fuel tanks being breached. The pilot estimated there was about 400 pounds in each tank at the time of the occurrence. Figure 1: Flight Track Plot The pilot noted that the airplane had undergone an annual inspection about 5 months before the accident, in March 2021. The airplane had accumulated about 20 flight hours since that inspection. During the examination of both the left and right engines, no evidence of a failure or anomaly was found. The left engine's compressor section showed the ability to rotate the first stage compressor wheel by hand, but the power section, specifically the propeller shaft, could not be manually rotated. The reduction gearbox had no damage to the case, but the propeller shaft was broken and the propeller flange was missing. Buckling was observed in the exhaust duct. The gas generator case, accessory gearbox, inlet case, and inlet screen were undamaged. The fuel control unit’s (FCU) connecting arm moved freely, but the reversing lever guide pin was bent and the carbon block was missing. The pneumatic lines, oil and fuel filters, power turbine (PT) blades, and first stageblades in the compressor section were intact and without damage. In the right engine, similar findings were observed with intact components in the compressor section, reduction gearbox, gas generator case, accessory gearbox, inlet case, and inlet screen. The power control linkage and reversing linkage were properly connected with intact hardware and safety mechanisms. The pneumatic lines, oil and fuel filters, PT blades, first stage blades in the compressor section, propeller shaft, and propeller retention bolts were undamaged. The controls and accessories, including the FCU, fuel pump, ignition system, fuel nozzles, flow divider, air system's bleed valve, propeller governor, and torque transducer, were all undamaged. Both fuel pumps were inspected, and no contamination was detected in the removed filters. A partial amount of fuel was found in both filter bowls. A complete examination of the fuel system could not be completed due to the damage incurred to the airplane at impact. According to the engine manufacturer, if an engine flames out in flight due to fuel starvation, it does not leave behind unique evidence different than a normal engine shut down. He added that both engines flaming out within a short time is not consistent with any dual-engine aircraft systemic design behaviors that could have occurred other than a fuel supply or delivery issue.

Aircraft

Registration
N783MB
Reported as
Cessna 425
Category
Airplane
Serial number
425-0103
Built
1982
Airframe hours
9,576
Engines
P&W PT6A-112, 550 horsepower, turbo propP&W PT6A-112, 550 horsepower, turbo prop
Damage
Substantial damage
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 28, 2021 · 10 hours before
Departed
FBL · Fairbault, MN
Destination
MSO · Missoula, MT
Flight plan
IFR
Airport
HLN · Helena Rgnl
Equipment
Onboard weather, Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight display

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
61
Injuries
Serious
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
6,000 total · 800 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 14 knots, gusting 25
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 46 °F
Altimeter
30.03 inHg
Observed at
KHLN, 8 nm away
METAR
KHLN 111353Z 27014G25KT 10SM CLR 23/08 A3003 RMK AO2 PK WND 26030/1259 SLP143 T02330078

Docket · 9

The files NTSB released with the investigation on September 20, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.2 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.