NTSB Factual Report

HISTORY OF FLIGHT

On January 22, 2009, about 1910 eastern standard time, a Cessna 402C, N2615G, registered to Hyannis Air Service, Inc., operated by Cape Air as Continental Connection Flight 9399, experienced a total loss of engine power from both engines and was not damaged during a forced landing at Naples Municipal Airport (APF), Naples, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 135 scheduled, domestic passenger flight from Key West International Airport (EYW), Key West, Florida, to Southwest Florida International Airport (RSW), Fort Myers, Florida. The airline transport-certificated pilot and six passengers were not injured. The flight originated about 1828, from EYW.

The incident flight was the pilot’s fourth leg that day in the incident airplane. Prior to the first flight that day from RSW to EYW operating as flight 9396, a total of 90 pounds of fuel were added to each main fuel tank. The fuel quantity gauges indicated 500 pounds total after fueling. The 55 minute flight (block time) to EYW was uneventful and was flown at 7,000 feet. He operated the airplane with each fuel selector positioned to its respective tank and did not crossfeed during this flight. After landing at EYW 90 pounds of fuel were added into each main tank. He did not recall the left or right fuel gauge reading after the fueling. He stated he did not recall a difference between the left and right fuel quantity indications.

The second flight that day from EYW to RSW, operating as flight 9397, was uneventful and flown at 6,000 feet. The flight lasted approximately 55 minutes (block time). He operated the airplane with each fuel selector positioned to its respective tank and did not crossfeed during this flight. After landing at RSW, 180 pounds of fuel were added into each main tank. He watched the fueling and also checked the fuel slip. After fueling, the fuel quantity gauges indicated a total of 650 pounds; the left fuel quantity gauge indicated 350 pounds and the right fuel quantity gauge indicated 300 pounds.

The third flight that day from RSW to EYW, was operated as flight 9398. Before departure he noted the 50 pound fuel imbalance. The flight departed with each fuel selector positioned to its respective fuel tank, and climbed to 7,000 feet. Upon reaching cruise, he set cruise power, then moved the right fuel selector to the left main fuel tank position (crossfeed). He stated that he believed he flew in this condition for 15 to 20 minutes in order to balance the fuel load. At the end of the estimated time he repositioned the right fuel selector to its respective tank then began to descend. He did not recall the left or right fuel quantity gauge readings at the end of the crossfeeding. The block time was 55 minutes or maybe 1 hour. No fuel was added at EYW.

The fourth flight that day from EYW to RSW (incident flight), was operated as flight 9399. The pilot did not visually inspect the fuel tanks before departure. Before takeoff, he noted the left fuel quantity gauge indicated 300 pounds and the right fuel quantity gauge indicated 200 pounds. He did a quick engine run-up before takeoff to check the operation of the magnetos with no discrepancies reported. He does not recall the seating positions but noted a male was in the co-pilot’s seat. He did brief the passengers; a total of 6 passengers were on-board. The flight departed with each fuel selector positioned to its respective tank, and while climbing to 6,000 feet, he noted the airplane appeared to be right wing heavy (slightly). He noted this but did not perform any action. He set cruise power and noted during cruise flight the left fuel quantity gauge indicated 280 pounds and the right fuel quantity gauge indicated 160 pounds. Approximately ½ way into the flight during cruise flight, he repositioned the left fuel selector valve to the right main tank position (crossfeed) and left it there for approximately 15 minutes. At that time the left fuel quantity gauge indicated 300 pounds and the right indicated between 100 and 90 pounds. He repositioned the left fuel selector to its respective tank position; at that time the flight was 60 to 55 nautical miles from RSW.

Air traffic control communications were transferred from Miami Air Route Traffic Control Center (Miami ARTCC), to Fort Myers Approach Control. He obtained the automated terminal information service (ATIS) from RSW, and when the flight was approaching Marco Island, the left fuel quantity gauge was indicating 300 pounds and the right fuel quantity gauge indicated 50 pounds. He stated he was “starting to get concerned.” When approaching Naples, Fort Myers Approach Control instructed him to descend to 4,000 feet. He was “still seeing 300 pounds on the left and below 50 pounds on the right.” He never operates the airplane below 100 pounds in either tank, and later stated he thought the fuel load difference was an indication issue. He later stated, “I was working on that problem” and when asked he stated he meant in his head. All engine instruments were normal.

The flight continued towards the destination airport and when past Naples flying at 4,000 feet over land, he was just about to call operations reporting in-bound and the right engine began surging first. He looked at the right fuel gauge and it indicated 0. The left fuel quantity gauge at that time indicated 300 pounds or “maybe north of that.” He immediately moved the right fuel selector to the left tank position (crossfeed), which restored engine power. He did not consider this an emergency at that time. The left engine then began surging, followed by the right engine. He repositioned the right fuel selector to its respective tank, adjusted power, and visually checked the positions of the fuel selectors, mixture controls, engine instruments, and magnetos. With respect to the magneto switches, he only visually verified they were on.

Unable to maintain altitude due to the loss of power from both engines, he declared an emergency with Fort Myers Approach Control and advised he needed to fly to APF. He was cleared to APF, did a 180 turn towards there, and while flying at 3,000 feet, he feathered the propellers and began looking for the APF airport. He saw the runway end identifier lights (REILS), and Fort Myers Approach asked him if he could see the APF airport. He stated he did, and aimed for the middle of the airport. The runway lights for runway 14 came into view and he lined up for runway 14. He held the gear until he was sure he could land on the runway then blew down the gear with the emergency blow down bottle. He landed with full flaps, and rolled to the end of the runway then onto a taxiway and stopped the airplane. He turned around to the passengers and the fire department (FD) showed up. He talked with FD personnel but doesn’t recall too much more. He did not recall moving the fuel selectors and stated he didn’t think he did. He also recalled that the right fuel quantity gauge precipitously went from 50 pounds to 0.

Five of the six passengers reported in writing that the left engine quit first followed by the right engine. One male passenger reported in writing that upon takeoff from EYW, the left fuel quantity gauge indicated “[300] lb and the right around [100] lb. On landing at Naples the left hand gauge showed [350] lb but the right showed empty.” All of the passengers reported the pilot told them to brace for impact and to make sure their seatbelts were tight.

The airplane was towed by Naples Airport Authority personnel to the ramp, and was put into a hangar later that evening and secured. Naples Airport Authority did not put any fuel into the airplane after it landed.

PERSONNEL INFORMATION

The pilot, age 63, holds an airline transport pilot certificate with rating(s) airplane single and multi-engine land, and a flight instructor certificate with ratings airplane single and multi-engine land, instrument airplane. He holds a first class medical certificate dated October 8, 2008, with limitations to wear lenses for distant vision and possess glasses for near vision.

The pilot was hired by Hyannis Air Service doing business as (dba) Cape Air in May 1993, and has been employed continuously since then with Cape Air. His last airman competency/proficiency check in accordance with 14 CFR Part 135.293 titled, “Initial and recurrent pilot testing requirements”, 14 CFR Part 135.297 titled, "Pilot in command: Instrument proficiency check requirements", and also 14 CFR 135.299 titled, “Pilot in command: Line checks: Routes and airports” was performed on November 21, 2008. The flight duration was recorded to be 1.4 hours and the results were listed as "Approved"; the flight was flown in the incident airplane. He was qualified to act as pilot-in-command (PIC) in Cessna 402C airplanes.

He reported on the NTSB Pilot/Operator Aircraft Accident/Incident Report having a total time of approximately 25,000 total flight hours, of which 20,000 hours were in the accident make and model aircraft. In the previous 90 and 30 days with respect to flight time in the incident make and model airplane, he reported accruing 308 hours and 78 hours, respectively.

AIRCRAFT INFORMATION

The airplane was manufactured in 1979, by Cessna aircraft Company as model 402C, and was designated serial number 402C0101. It is powered by two 325 horsepower Teledyne Continental TSIO-520-VB engines and McCauley constant speed propellers.

The airplane's fuel system consists of one integral fuel tank installed in each wing which in normal flight supplies fuel to each respective engine. Two fuel selector handles located in the cockpit (identified as left and right) are mechanically linked to a fuel selector valve located in each wing. The fuel selector allows for the selection of fuel being supplied to the engine from its respective main tank (normal flight condition), or cross feed. The fuel selector can also be turned off in the case of emergency. Fuel may be cross fed from the left main tank to the right engine or from the right main tank to the left engine by positioning both selector valves to the desired fuel tank. As an example, having both fuel valves positioned to the right main tank position will supply fuel to both engines from the right main fuel tank.

The airplane is maintained in accordance with (IAW) an FAA approved aircraft inspection program (AAIP) specified in 14 Code of Federal Regulations (CFR) Part 135.419. There are six operational inspection phases each performed at 60 hour intervals, with a complete cycle in 360 hours. They also have special inspections; none of which at the time of the incident related to the fuel selector valve. The AAIP is based on Cessna’s Progressive Inspection Program. While the airplane manufacturer maintenance manual specifies to inspect and service the fuel selector gearbox every 200 hours, the operator's AAIP only specified to lubricate the fuel selector gearbox during the Phase 3 inspection, which is performed every 360 hours.

While the maintenance manual and the AAIP Phase 3 inspection contained nearly the same verbiage pertaining to servicing of the fuel selector gearbox, neither specifically mentions to lubricate the fuel selector detents. The Cessna maintenance manual specifies to inspect and lubricate the fuel selector gearbox at the first 100 hours and every 200 hours thereafter or 1 time a year. Chapter 12-20-07 page 301, Figure 301 of the Cessna Maintenance Manual specifies what components of the fuel selector valve and gearbox are to be lubricated, by how (hand method), and what type grease (MIL-G-21164 low temperature grease).

Review of the airplane maintenance records revealed the last Phase 3 inspection was performed on September 30, 2008, at aircraft total time 23,218.50 hours. The airplane total time at the time of the incident was 23,631.0 hours. Further review of the maintenance records revealed the left fuel selector valve was replaced at June 17, 2005. The airplane had been operated for approximately 3,511 hours since the left fuel selector valve was replaced; the fuel selector valve is an on-condition item.

Safety Board review of the Aircraft Flight Log which reflect in part date, flight, and discrepancy information revealed that between October 17, 2008, and January 22, 2009, there were no entries related to either fuel selector valve. Between these dates the airplane had been operated approximately 362 hours.

Post incident, the operator removed and replaced the left fuel selector valve control cable and left fuel selector valve.

METEOROLOGICAL INFORMATION

A surface observation weather report taken at Naples Municipal Airport at 1853, or approximately 17 minutes before the incident indicates the wind was from 330 degrees at 3 knots, the visibility was 10 statute miles, and clear skies existed. The temperature and dew point where 13 and 3 degrees Celsius, respectively, and the altimeter setting was 30.26 inches of mercury.

COMMUNICATIONS

The pilot was in contact with Fort Myers Approach Control, there were no reported communication difficulties.

AIRPORT INFORMATION

The Naples Municipal Airport (KAPF) is a contract tower controlled facility that has two runways designated 05/23 and 14/32. Runway 14/32 is 5,000 feet long and 75 feet wide. The local control frequency is 128.5 MHz.

WRECKAGE AND IMPACT INFORMATION

Inspection of the airplane the following day revealed no damage to the airplane; both propellers were in the feathered position. The left main fuel tank contained 275 pounds of fuel as indicated by the fuel quantity gauge and the right main fuel tank was drained and found to contain approximately 13 gallons of fuel. The flexible fuel lines in each engine compartment contained only trace amounts of fuel, and no water contamination was noted in any of the eight fuel samples taken (four per wing).

The left fuel selector handle in the cockpit appeared to be in the left main tank position; however, the fuel selector valve located in the wing was between the left and right main tank positions. The right fuel selector valve was in the right main tank position. Continuity of both fuel selectors was noted from the cockpit selector handle to each selector valve. Examination of the left fuel selector cable at the gearbox and valve revealed no evidence of grease specified by the Cessna maintenance manual. There was evidence of a light coating of lubricant at the plunger/piston at the valve and also at the gearbox. Examination of the right fuel selector cable at the gearbox and valve revealed no evidence of grease specified by the Cessna maintenance manual. There was evidence of a heavy coating of red/brown colored grease at the gearbox, and also evidence of a light coating of lubricant on the cable at the valve.

Testing of the as-found position of the left and right fuel selector valves revealed no flow for the left engine during primer activation, but fuel flow was noted for both engines during primer activation for the right engine.

Operational testing of the left fuel selector was performed which revealed that when it was placed to right main tank, a click was heard and the valve moved to the detent, but a detent could not be felt in the cockpit. The left fuel selector was then moved to the left main tank position and it was reported to feel “spongy”; a detent was not felt. The left fuel selector was then moved to the stop but the valve did not go into the detent. The valve moved to 9/32 inch extension, which was 1/32 inch greater than the as-found position. With electrical power applied and left fuel selector valve moved to the stop and the left primer was actuated, the fuel selector valve moved to the main tank detent and fuel flow increased, i.e. fuel pressure moved the fuel selector valve into the main tank detent. Operational testing of the right fuel selector revealed positive detents could be felt.

Operational testing of both engines was performed twice using the fuel contained in the airplane at the time of the incident. Based on the as-found position of the left fuel selector valve (between left and right main tank positions

NTSB Probable Cause

The pilot's failure to recognize that both engines were being supplied fuel only from the right main fuel tank, resulting in fuel starvation and a subsequent loss of engine power from both engines. Contributing to the incident were the pilot's inability to properly position the left fuel selector valve and the airplane operator's misinterpretation of the manufacturer's service recommendations to lubricate the fuel selector detents.