NTSB Factual Report

HISTORY OF FLIGHT

On August 19, 1999, about 0317 eastern daylight time, a Cessna 210L, N640AJ, registered to and operated by Flight Express, Inc., as flight 812, collided with a building approximately 3/4 mile north of the approach end of runway 18L, at the Tampa International Airport, Tampa, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 135 non-scheduled, domestic, cargo flight. The airplane was destroyed and the airline transport-rated pilot, the sole occupant, was fatally injured. The flight originated about 0208 from the Fort Lauderdale Executive Airport, Fort Lauderdale, Florida.

After takeoff, air traffic control (ATC) communications were transferred from the Fort Lauderdale Executive Air Traffic Control Tower to Miami Approach Control. The flight remained in contact with that facility from 0209 to 0215, when ATC communications were transferred to the Miami Air Route Traffic Control. The flight remained in contact with that facility until 0256, when ATC communications were transferred to Tampa Approach Control.

According to a transcription of communications with Tampa Air Traffic Control Tower, at 0257:21, the pilot contacted the facility and advised the controller that then flight was at 6,000 feet with Automated Terminal Information Service (ATIS) "delta." The controller advised the pilot to proceed direct "tampa" and descend at pilot's discretion to 3,000 feet. The pilot acknowledged the transmission, the flight continued and at 0307:03, the pilot advised the controller that the field was in sight. At 0307:37, the pilot advised the controller "and for express eight twelve we're expecting three six right." The controller advised the pilot, "well expect one eight left you'll be following company uh north of the airport." The pilot repeated the instructions from the controller to expect runway 18L. At 0307:54, the pilot stated, "express eight twelve any chance we can (unintelligible) three six right." The controller advised the pilot to fly heading 350 and, "...you're tied with company landen [sic] eighteen." The pilot acknowledged the heading to fly. At 0311:57, the controller advised the pilot that the company traffic was located at his ten o'clock position and about 3 miles. The pilot advised the controller that the traffic was in sight and the controller advised the pilot to follow the company traffic and cleared for a visual approach to runway 18L, and also cleared to land. The pilot repeated the instructions that the flight was number 2, cleared to land runway 18L. At 0316:32, the pilot stated, "tampa flight express eight twelve is declaring an emergency." The controller responded, "flight express eight twelve go ahead", the pilot responded, "flight express eight twelve uh." There were no further recorded transmissions from the accident pilot.

A witness reported hearing what sounded like a car was backfiring. He observed a small airplane and heard the engine sputtering then stop sputtering which continued for five to eight times before the airplane was out of sight. A copy of the witness statement is an attachment to this report.

According to the pilot of the company airplane that was flying ahead of the accident pilot, after landing she looked back and observed the accident airplane to be 1-2 miles out with all lights on; she expected the airplane would be closer than observed. She reported turning onto taxiway "Hotel", and heard the accident pilot report an emergency. She reported turning onto the taxiway, looked to the left and did not see the aircraft's lights but did see a bright flash. She reported that the initial time from the emergency declaration by the pilot to seeing the bright flash was approximately 30 seconds.

The airplane collided with power lines then a structure, and remained supported on top of the structure.

PERSONNEL INFORMATION

Review of the Federal Aviation Administration (FAA) records revealed that the pilot was issued an airline transport pilot certificate with the rating airplane multi-engine land, on May 16, 1999. He was also the holder of a commercial pilot certificate with the rating airplane single engine land. He was issued a flight instructor certificate with the ratings airplane single and multiengine, instrument airplane. The flight instructor certificate was scheduled to expire September 30, 1999. He was issued a first class medical certificate on March 19, 1999, with no limitations.

The pilot's date of hire with the operator as a full-time pilot was August 31, 1998; he was initially qualified to act as pilot-in-command in Cessna 210 airplanes. He completed his ground training and training specific to the Cessna 210, on August 31, 1998. On November 10, 1998, he received a checkride in accordance with 14 Code of Federal Regulations (CFR) 135.293, 135.297, and 135.299, which qualified him to act as pilot-in-command in IFR and VFR conditions. According to the Director of Operations, the pilot's last day as a full-time pilot was July 30, 1999; he was a part-time pilot for the company at the time of the accident.

Review of the pilot's pilot logbook revealed that he had logged approximately 2,219 hours total time, of which approximately 2,022 hours were logged in single-engine airplanes.

AIRCRAFT INFORMATION

Review of the airplane maintenance records revealed that on April 5, 1995, the fuel tanks were drained and the fuel gauges were calibrated to zero in accordance with Airworthiness Directive (AD) 94-12-08, which had an effective date of July 22, 1994. According to a FAA airworthiness inspector, postaccident examination of the aircraft and the aircraft's records revealed the procedures required in part by the AD pertaining to incorporating information into the airplane flight manual or airplane records could not be located. A copy of the statement from the FAA inspector is an attachment to this report.

Review of the airplane maintenance records revealed the last recorded discrepancy pertaining to the fuel gauges was dated January 13, 1999. That entry indicated, "left fuel gauge inop [sic]." The corrective action for the discrepancy states, "written in error op's [sic] [check] good." There were no further entries pertaining to the discrepancies of the fuel gauges. Copies of the maintenance records are an attachment to this report.

The last annual inspection to the airplane was performed on June 1, 1999. The airplane had accumulated approximately 231 hours since inspection at the time of the accident. The airplane was inspected in accordance with a Phase 1 inspection on August 9, 1999; the airplane had accumulated approximately 37 hours since then at the time of the accident. The phase 1 inspection is a company aircraft status check performed between required annual inspections.

Review of the airplane type certificate data sheet indicates that the unusable fuel quantity is 6 pounds, which equates to 1 gallon of fuel.

METEOROLOGICAL INFORMATION

A special METAR weather observation taken at the Tampa International Airport, at 0327, indicates that the wind was variable at 3 knots, the visibility was 10 statute miles, few clouds at 1,200 feet, scattered clouds at 25,000 feet, the temperature and dew point were 75 and 73 degrees Fahrenheit respectively, and the altimeter setting was 29.96 inHg. The Tampa International Airport was located 186 degrees and 1.59 nautical miles from the accident site.

COMMUNICATIONS

The pilot was in contact with Tampa Air Traffic Control Tower (Tampa ATCT), a transcription of communications is an attachment to this report.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed into property located at 5110 W. Clifton Street. That location was determined using a portable global positioning system (GPS) receiver to be located at 28 degrees 00.074 minutes North Latitude and 082 degrees 31.697 degrees West Longitude. That location when plotted was located 356 degrees and .79 nautical mile from the approach end of runway 18L.

Examination of the accident site revealed damage to two power lines north of where the airplane came to rest. The power lines were located 49 feet apart. Impact damage to the northern side of a dust bin located approximately 45 feet from the second power line contact was noted. The impact damage on the dust bin was located approximately 23 feet above ground level and was associated with the left wing (see photograph No.3). The orientation of the dust bin contact was on a magnetic heading of 186 degrees. The spacing of the vertical supports of the dust bin correlate with the spacing of the damage on the leading edge of the left wing. The impact signature on the dust bin made by the left wing was oriented on a 20-degree angle of bank to the right. The airplane came to rest on a magnetic heading of 099 degrees, located on top of the dust bin approximately 56 feet from the second power line contact location (see photograph No. 1). No fuel leakage was noted on the ground beneath the nose section of the airplane, or beneath the impacted dust bin. The airplane was recovered for further examination.

Examination of the airplane revealed a power line wire was wrapped around the right horizontal stabilizer. A mark on the leading edge of the left wing was noted. The propeller was separated from the engine which remained partially attached to the airframe. Flight control cable continuity was confirmed for pitch and yaw. The left aileron control cable was broken at the left door-post area; no evidence of preimpact failure or malfunction was noted on the broken cable. The left wing fuel tank was compromised; no fuel leakage was noted from the tank beneath the impact point of the dust bin or beneath the resting point of the left wing. No fuel stains were noted aft of the fuel filler cap, near the tank sump drain valve, or near the impact damaged header tank. No fuel was found in the left header tank. Examination of the right wing of the airplane revealed no evidence of structural compromise of the fuel tank; the tank was drained and found to contain approximately 5 ounces of fuel. No fuel stains were noted aft of the fuel filler cap or near the tank sump drain valve. Two ounces of fuel were drained from the right header tank. Approximately 3 drops of fuel were drained from the gascolator; all fuel lines "B" nuts were tight and no fuel stains were noted. Approximately 1/2 teaspoon of fuel was drained from the auxiliary fuel pump which was tested and found to operate when electrically powered. No more than approximately 10 ounces of fuel total were drained from the airplane (see photograph No.9). Placards were found adjacent to both wing tank receptacles (see photographs Nos. 6 and 7). The pilot's lapbelt was fastened; the shoulder harness was not attached to the lapbelt assembly. The structure where the pilot's outboard lapbelt attaches was separated from the airplane. The flaps were retracted; the emergency locator transmitter (ELT) did not activate. Testing of the fuel gauges with electrical power supplied to the in-line fuse at the buss bar assembly and both fuel probes of each tank submerged in glass jars filled with 100 low lead fuel revealed movement of the left gauge needle with removal of the probes from the fuel. No needle movement was noted from the right fuel gauge. The right wire from the fuel quantity control monitor box was then connected to the left fuel gauge, and with power supplied and removal of both probes from the fuel, needle movement was noted. With both probes of the right fuel tank removed from the fuel, the needle did not indicate empty (see photograph Nos. 10-15). Visual examination of the cluster gauge assembly revealed the electrical power terminal stud was resting against the aft side of the meter movement backing plate. Additionally, the right fuel gauge faceplate was not in a normal position (see photograph No. 8). The cluster gauge assembly and ELT were removed from the airplane for further examination (see Tests and Research section of this report).

Examination of the engine revealed that the crankshaft was fractured inside the crankcase. Rotation of the engine by hand revealed continuity of the crankshaft from the fracture surface to the rear of the engine, continuity of the camshaft, and valve train continuity. The throttle control was connected and the butterfly was in the "idle" position. The mixture control was also connected and was in the idle "cut off position." The inlet fitting at the engine driven fuel pump was fractured. Both magnetos were tight on the accessory case with no evidence of slippage; both magnetos sparked at all towers when rotated by hand. Examination of the spark plugs revealed they had light wear and very light deposits; the electrode areas were light gray in color. Examination of the engine driven fuel pump revealed a few drops of fuel at the inlet, the drive coupling was not failed and the unit was free to rotate. Disassembly of the pump revealed no evidence of internal damage. No fuel was found in the fuel metering unit. Drops of fuel were noted in the fuel line from the fuel metering unit to the flow divider. Residual fuel was noted in the flow divider; the screen in the flow divider was clean. Additionally, the main fuel screen was also clean. A copy of the report from the representative of the engine manufacturer is an attachment to this report.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed by Russell S. Vega, M.D., Associate Medical Examiner, Hillsborough County, Florida. The cause of death was listed as basilar skull fracture and craniocervical dislocation due to blunt impact to head.

Toxicological testing of specimens of the pilot were performed by the Federal Aviation Administration (FAA) Toxicology and Accident Research Laboratory (CAMI), and the Hillsborough County Medical Examiner Department. The results of analysis by CAMI was negative for carbon monoxide, cyanide, and ethanol. Theophylline (13.73 ug/mL, ug/g) was detected in the urine. The results of analysis by the Hillsborough County Medical Examiner's Office was negative when testing ocular fluid, peripheral blood, and cavity blood for listed drug classes. Copies of the reports are an attachment to this report.

TESTS AND RESEARCH

The accident occurred on the fourth and final leg of the scheduled flights; the four legs were designated route procedure 812-01 through -04, respectively. The scheduled landing time for route procedure 812-01 is 1815 hours local; and after landing "fuel aircraft - top off." The scheduled upload time for route procedure 812-02 is 2125 hours. No adverse weather was recorded at the first leg airport at 1753, 1853, 1953, 2053, or 2153 hours local. The airplane was not fueled while at that location, or after landing following the second or third flight legs. After landing following the first leg, the pilot logged flying a total of 1.8 hours in a multi-engine airplane, 1.5 hours of which was as a flight instructor. The pilot had also logged between July 20, 2000, and August 17, 2000, 6 flights in an airplane other than the company airplane between the first and second legs of the scheduled four-leg sequence. The pilot had flown that same route procedure five times during the month of August.

The airplane was fueled last by the pilot at 0358 hours on August 18, 1999, while using the operator's fuel facility at the Tampa International Airport; 65.9 gallons of fuel were added. Using the flight times contained in paperwork located in the wreckage and the accident flight duration, the airplane had been operated for 4 hours 54 minutes since fueling.

Review of the pilot's copy of the airplane operator General Operations Manual found in the wreckage revealed Safety Bulletin Number SB-01, which pertains to "Cessna 210 Fuel Tank Capacity." A copy of the safety bulletin is an attachment to this report.

Testing of the right fuel gauge which by design is installed in the cluster gauge assembly, was performed by Cessna Aircraft Company personnel with Federal Aviation Administration (FAA) oversight. The testin

NTSB Probable Cause

The failure of the pilot to follow procedures and directives established by the operator for his failure to fuel the airplane after landing following the first leg. Contributing to the accident was the total loss of engine power due to fuel exhaustion. Findings in the investigation were 1) the failure of company maintenance personnel to comply with all instructions of Airworthiness Directive (AD) 94-12-08, and 2) the pilot flew a total of 1.8 hours in a multi-engine airplane after the first leg landing; 1.5 hours of which were as a flight instructor.