NTSB Factual Report

HISTORY OF FLIGHT

On June 26, 2008, about 1756 eastern daylight time, a Cessna 310R, N4912A, registered to a private individual and operated by Marco Aviation, Inc., experienced total loss of engine power from both engines and was ditched in the Gulf of Mexico near Goodland, Florida. Visual meteorological conditions prevailed and a visual flight rules (VFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 135 non-scheduled, domestic, passenger flight. The flight departed from Key West International Airport (EYW), Key West, Florida, and was destined to Marco Island Airport, (MKY), Marco Island, Florida. The airplane sustained substantial damage and the certificated airline transport pilot (ATP) plus one of five passengers were not injured. Three passengers sustained minor injuries and one passenger sustained serous injury. The flight originated about 1722, from EYW.

The pilot stated that before takeoff, he did not check the fuel tanks and he did not brief the passengers on the emergency procedures. He reported the reason he did not brief them was because he had flown them earlier that day from MKY to EYW, and had briefed them before that flight. Before departure of the accident flight, the weight and balance form reflected that the fuel load was 280 pounds, which agreed with the reading on the fuel quantity indicator. The right fuel quantity was indicating a slightly higher amount than the left. He thought he had an adequate fuel supply for the flight, and operates the engines with both mixture controls in the full rich position. After takeoff, the flight climbed briefly to 3,000 feet mean sea level (msl), then descended to and remained at 2,500 feet msl, and proceeded to the destination airport. When the flight was near the destination airport, he reduced both throttles to 21 inches manifold pressure, and began descending at less than 500 feet-per-minute. Approximately 15 miles from MKY, while flying at 1,500 feet msl, the right engine "coughed a couple times" with corresponding right yaw. He noted the right fuel flow was "down" and described a split between the left and right fuel flow readings. He turned the right auxiliary fuel pump to the low position, and moved the right fuel selector to the "left main" position in an effort to restore engine power. The engine kept surging, so he feathered the right propeller. At that point he advised the passengers to don their life vests, which were located on a shelf behind the 3rd row of seats.

The pilot announced on the MKY common traffic advisory frequency (CTAF) that he was operating single-engine, and to clear the traffic pattern. Personnel of a fixed base operator (FBO) at MKY, who heard the communication immediately called 911 to request assistance, and remained in contact with the pilot. The pilot further stated that while flying single-engine, he maintained 120 to 130 knots, and stopped descending at 800 feet msl. At approximately 1758, a pilot with Collier County Sheriff Department Aviation Unit (Collier County SD) was alerted to the need for assistance, and within 4 minutes departed from Naples Municipal Airport (APF) and proceeded to the area where the airplane was reported to be located.

The accident pilot further stated that approximately 4 minutes after the right engine began losing power, and when the flight was 9 miles from MKY, the left engine began indications similar to the right engine, and then quit. The pilot announced on MKY CTAF that he would be ditching and to send help. He switched the left fuel selector to the right main tank position in an effort to restore engine power, which was unsuccessful. He recalled the left propeller did not feather, and in preparation for ditching, reviewed in his mind the ditching procedures, which were full flaps extended and gear up. He slowed to 93 knots, and just before ditching, he placed his arm in front of the 10 year old passenger seated in the copilot's seat. Also, just before ditching, the left and right fuel quantity were indicating 70 and 100 pounds, respectively.

The airplane first contacted the water with the curved portion of the bottom of the fuselage, and lunged forward, then rebounded. After coming to rest, the pilot attempted to open the cabin door but felt resistance. He then opened the emergency exit window, and was able to fully open the cabin door. All occupants exited the airplane from the cabin door, with one passenger reporting he was the last person out of the airplane because he was looking, but could not find a life vest for himself. All occupants then stayed momentarily on one of the wings, but the airplane began to submerge. They then entered the water and the pilot tried to keep everybody together, but it was difficult due to the waves. The pilot helped one passenger inflate the second chamber of her life vest, and noted that another passenger that did not have a life vest was clinging to two of his daughters.

The passenger without the life vest reported that he was clinging to his daughters for support, and contemplated pushing away from them because he was concerned about their safety trying to keep him afloat, but about that time he spotted a helicopter.

The flightcrew of the Collier County SD helicopter that proceeded to the area first spotted the occupants at 1820, or approximately 24 minutes after the ditching, and immediately flew to a nearby boater and motioned for the boater to follow the helicopter. The boater proceeded to the area and all occupants were placed in the boat. Additionally, emergency medical service personnel boarded the boat and remained with the pilot and passengers until their transfer to land, where they were then transported to a hospital. The pilot reported to a Collier County SD individual and also to one passenger, while on the boat, that he ran out of fuel. He also told the passenger that the fuel gauges were incorrect.

The airplane was ditched during daylight hours, approximately 11 nautical miles south-southeast from the center of MKY.

PERSONNEL INFORMATION

The pilot, age 65, held an ATP certificate with a rating airplane multiengine land. Numerous type ratings for transport category airplanes are listed on his ATP certificate. He also held a commercial pilot certificate with an airplane single-engine land rating, and was issued a first-class medical certificate on December 3, 2007. The medical certificate listed a limitation that the holder must have available glasses for near vision and was not valid after December 31, 2008.

The pilot verbally reported to NTSB personnel that he is a retired airline pilot and has flown general aviation type airplanes, having accrued approximately 1,500 hours in various makes and models. The pilot reported on the NTSB “Pilot/Operator Aircraft Accident/Incident Report” having a total time of over 18,000 hours, and approximately 200 hours in the accident make and model airplane.

The pilot began his initial ground training with Marco Aviation, Inc., on December 1, 2007, and completed it on January 20, 2008. He began his initial flight training on January 7, 2008, and completed it on January 16, 2008; accruing 15.9 hours. His airman competency/proficiency check in accordance with 14 CFR Part 135.293 and 135.299 occurred on February 4, 2008. He was qualified to act as pilot-in-command (PIC) in Cessna 310R airplanes, and prior to being hired had not previously flown a Cessna 310 type airplane.

Since employment, he reported accruing approximately 200 hours in the accident make and model airplane. For the month of May he logged approximately 40 hours during the course of 52 flights in the accident airplane. For the month of June, excluding the accident date, he logged approximately 29 hours during the course of 38 flights in the accident airplane. On the accident date, excluding the accident flight, he logged 3 flights in the accident airplane.

AIRCRAFT INFORMATION

The airplane was manufactured in 1978, by Cessna Aircraft Company as model 310R, and was designated serial number 310R1399. It was certificated in accordance with Civil Air Regulation (CAR) 3 and sections of 14 CFR Part 23. It was powered by two 285-horsepower Teledyne Continental Motors IO-520 engines and equipped with two McCauley constant-speed, full-manual-feathering propellers. It was also equipped with three rows of two forward facing seats in each row.

Safety Board review of CAR 3 pertaining to unusable fuel revealed that amount is the amount at which the first sign of a malfunction occurs. With respect to the fuel quantity indicator, the regulation required that it be calibrated to read zero during level flight when the quantity of fuel remaining in the tank is equal to the unusable fuel supply.

The airplane’s fuel system consists of a 51.0 gallon total capacity aluminum tank attached at each wingtip, and also a 32.0 gallon total capacity bladder tank installed in each wing. The total usable capacity of each main and auxiliary fuel tank is 50.0 and 31.5 gallons, respectively. A dual fuel quantity indicator installed in the co-pilot’s instrument panel reflects the quantity of fuel in the tank selected at the fuel selector. The fuel quantity indicating system consists of a capacitance type probe installed in each tank, associated wiring to a signal conditioner installed in each wing, and associated wiring connected to the fuel quantity indicator.

Review of the maintenance records revealed the airplane was last inspected in accordance with a 100-Hour inspection on April 24, 2008; the airplane total time at that time was 8,835.6 hours. The airplane had accumulated 78.3 hours since the last 100-Hour inspection.

Further review of the airframe maintenance records that begin with the first entry dated August 21, 1978, to the last entry dated April 24, 2008, revealed there were two entries indicating calibration of the fuel indicating system. The first entry was dated February 19, 1988, at an airplane total time of 2,707.4 hours and the second entry was dated August 21, 1995, at an airplane total time of 3,920.6 hours. There was no record of removal, repair, or replacement of either main tank probes, either signal conditioner, or fuel quantity indicator. Calibration of the fuel quantity indicating system is not periodically required, but is required when components of the system such as the probes or signal conditioners are removed and replaced. Special test equipment is required to perform the test.

METEOROLOGICAL INFORMATION

A surface observation weather report taken at Naples Municipal Airport (APF), Naples, Florida, at 1753, or approximately 3 minutes before the accident indicates the wind was from 070 degrees at 10 knots, the visibility was 10 statute miles, and few clouds existed at 3,500 feet. The temperature and dew point were 30 and 23 degrees Celsius respectively, and the altimeter setting was 30.09 inches of Mercury.

COMMUNICATIONS

While proceeding towards MKY, the pilot established contact with the MKY airport on the CTAF and advised that he was operating single-engine and requested the traffic pattern be cleared of other airplanes. An individual at an FBO at MKY broadcast on the CTAF asking the accident pilot for clarification, but the pilot did not reply. Another FBO employee broadcast on the CTAF asking the pilot what was the nature of the problem, then asked him for the number of people on-board, the amount of fuel on-board, the location, and the nature of the problem. The pilot advised the number of people on-board, and the fact that he was operating on one engine, but did not report the on-board fuel load. The FBO employee advised the pilot that he would be contacting emergency services and called 911.

The FBO employee further advised the 911 operator that the pilot of a twin-engine airplane was inbound to MKY with one engine inoperative, and requested emergency services respond to MKY. While on the phone with the 911 operator, the pilot announced on the CTAF that the other engine had quit, he was going to ditch the airplane, and the flight was located 6 miles south of MKY. The 911 operator was updated as to the location and the ditching intention.

The CTAF at MKY is not recorded.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in approximately 7 feet of water and was located on a magnetic heading of 080 degrees. The airplane was raised using airbags and towed to shore where lifting straps were placed just outboard of each engine nacelle. Damage to both wings in the area of both straps was noted.

Examination of the airplane following recovery revealed damage to the main spar of the right wing near the wing root area. Control continuity for the primary and secondary flight controls were confirmed. All three landing gears were retracted and the flaps were extended, but the flap actuator was not measured to determine flap extension.

Examination of the airframe following recovery revealed no evidence of fuel stains at any fuel caps or fuel drains. Each main and auxiliary fuel tank were drained using the sump drain; all contained salt water. Only the left main fuel tank was found to contain any fuel; a total of 14 ounces of blue colored fuel consistent with 100 low lead aviation gasoline (100LL) were drained from that tank. Due to the fact that the airplane was submerged for several days, no attempt was made to apply power to the airplane’s electrical system. The left and right signal conditioner and each probe from the left and right main fuel tanks were removed for further examination.

Examination of the dual fuel quantity indicator in the cockpit revealed water was trapped inside the instrument. The left pointer was indicating approximately 210 pounds, while the right pointer was off scale low. No obvious impact damage was noted to the instrument or to the surrounding area of the instrument panel. The fuel quantity indicator was retained for further examination. Further examination of the cockpit revealed a portable global positioning system (GPS) receiver was mounted to the pilot’s control yoke. The GPS receiver was retained for further examination.

Examination of the cockpit and cabin revealed all seats remained attached to their respective attach points, with no observed deformation to any seat. No shoulder harnesses were installed at any seat position; all lapbelts were found released and were noted to latch and release with no discrepancies noted. No life vests were found in the pilot’s seat pocket, the cockpit, or cabin.

Examination of both engines revealed corrosion attributed to salt water submersion; no mechanical or impact damage was noted. The lower spark plugs of all cylinders were removed and the crankcases of both engines were flushed with fresh water. Fresh water was also sprayed on the exterior of both engines and engine accessories, and both magnetos of both engines were flushed inside and out with fresh water. A corrosion inhibiting spray was applied to all cylinder walls of all cylinders of both engines. Each engine-driven fuel pump was removed for visual inspection; each drive coupling was not fractured. The flexible fuel hoses in each engine compartment were all secured and intact. No fuel was found in any fuel line; however, a smell of fuel was noted when the fuel lines were removed. The fuel lines were then reinstalled. Visual inspection of the left propeller revealed all blades appeared to be in the low pitch position and exhibited varying degrees of aft bending. Visual inspection of the right propeller revealed all blades were in the feathered position. Both propellers were removed from the engines, which were then removed from the airframe.

Both engines were taken to a Federal Aviation Administration (FAA) certified repair station for operational testing with NTSB oversight. A test club propeller, appropriate for the engine make and model, was utilized for the test runs. With respect to the left engine, the spark plugs were removed and cleaned to remove corrosion, and the point of each magneto was lightly cleaned with sandpaper to remove corrosion. The engine was started and operated; however, the engine ran rough when the left magneto was grounded. The right magneto was removed and a serviceable unit was installed. The engine was resta

NTSB Probable Cause

The pilot’s inaccurate fuel consumption calculations, which resulted in a total loss of engine power to both engines due to fuel exhaustion.