Pilot Debrief

CESSNA 337A near West Creek, NJ — 2008-05-17

Final reportNYC08FA184
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Date
2008-05-17
Location
West Creek, NJ, USA
Airport
31E
Aircraft
CESSNA 337A
Registration
N5382S
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Descent

Probable cause

The pilot's departure with insufficient fuel for the planned flight, and his improper in-flight fuel management, which resulted in a total loss of power in both engines due to fuel starvation. Contributing to the accident was the pilot's fatigue, which was precipitated by his work activities during the days just prior to the accident flight.

Contributing factors

Contributing to the accident was the pilot's fatigue, which was precipitated by his work activities during the days just prior to the accident flight.

NTSB narrative

The multi-engine airplane was one of several owned and operated by the pilot, who flew many of the missions, and conducted most of the maintenance. The three passengers were employees of an environmental services company that was contracted to conduct aerial surveys of marine mammals. Each month, the pilot re-positioned the airplane from his base in Massachusetts to New Jersey to conduct the survey flights. The previous month, the survey personnel documented concerns with the pilot's performance, and the condition of the airplane. For the accident flight series, the pilot arrived 1 1/2 days late, and one surveyor documented the passengers' concerns about the pilot's performance and fatigue. About 90 minutes into the accident flight, the pilot informed the passengers that he "was having some fuel problems," terminated the survey, and diverted for a precautionary landing. One passenger saw the front propeller stop and begin rotation more than once. The airplane impacted trees and terrain approximately 400 feet to the side of the runway threshold. Several witnesses saw the airplane descend, heard it crash, and notified authorities, but the unsuccessful search efforts were terminated about 2 hours after the accident. A surviving passenger used his mobile phone to call for assistance, and the wreckage was located about 2 hours after that, which was about 4 hours after the accident. The pilot and a passenger were killed, and two passengers survived. Autopsy results indicated that the pilot incurred a transected aorta, which is a non-survivable injury. The fatally-injured passenger incurred a cervical fracture and a transverse basilar skull fracture. Though such injuries are commonly fatal, it is possible that appropriate and more immediate medical treatment would have increased the chances of the passenger’s survival. Post accident examination. Post accident examination revealed that the battery for the emergency locator transmitter bore a "replace by" date that was four years prior to the accident. Neither propeller exhibited evidence of rotation during impact. While all fuel tanks were intact, the main tanks were empty, one auxiliary tank contained 11 gallons, and the other one contained 2 gallons. Records indicated that the airplane was not refueled between the previous flight and the accident flight. The manufacturer's Owner's Manual indicated that the engines can only be primed from the main tanks, and the "Engine-Out During Flight" checklist specified that the fuel selector valve should be set to the main tank for an engine restart attempt. Both engines were successfully test-run after the accident.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot should have diverted earlier when fuel issues were first noted.

NTSB coding

Evidence available

  • Photos
  • 34 docket documents
View NTSB final reportView NTSB docket

Docket documents34

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