NTSB Factual Report

HISTORY OF FLIGHT

On September 24, 2001, approximately 1615 mountain daylight time, a Cessna 337B, N337PM, operated by Aero West Jet Center, was destroyed when it collided with a powerline and impacted a highway in the town of St. George, Utah. The airline transport certificated pilot, the sole occupant aboard, was fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the ferry flight being conducted under Title 14 CFR Part 91. The flight originated in Mesquite, Nevada, approximately 1555.

The owner brought the airplane to St. George in April 2000 to have it completely restored. The pilot flew the airplane to Mesquite on February 8, 2001, where it was repainted. The interior --- including avionics and most of the instruments --- had been removed, and refurbishing was scheduled for a later date. On the day of the accident, a flight student of the pilot, who was a flight instructor, flew him to Mesquite in a Cessna 172. The pilot was to ferry N337PM back to St. George. The student watched the pilot sump both inboard wing tanks. When no fuel came out of the right inboard tank, the pilot taxied the airplane over to the fuel pumps, and told the student to "put 15 gallons [of fuel] in each side." In an interview conducted on September 26, the student was asked to identify which tanks he fueled. Using another Cessna 337 parked on the ramp at St. George, he pointed to the left and right inboard tanks. When the refueling was finished, the pilot started both engines, taxied to the runway, and took off. The student followed in the Cessna 172, but never acquired visual contact with N337PM.

There were at least 29 witnesses to the accident, 20 of whom gave written statements for the police report. Seven oral statements were received. Two additional written statements were submitted directly to investigators. When witness #1 (a pilot and FAA-designated aviation safety counselor) first saw the airplane, the pilot was "executing a missed approach [to] runway 34 approximately 50 feet above the ground." A Cessna 172 took off from runway 16 which "caused a conflict requiring the missed approach." He said the accident airplane turned west, dropped below field elevation, reappeared, then turned south. It "appeared to be struggling for altitude in a high angle of attack, approaching a stall and then recovering to normal flight." The airplane then turned east, crossed the departure end of runway 16, "dropped again below field elevation and turned north, close in on downwind, continuing the cycle of near stall and recovery." The witness listened for the sound of engines and noted "a full power sound of one engine," but it was "lacking the familiar rear engine propeller sound which is normal for a Skymaster."

Witness #2, an instructor aboard a departing Cessna 150 saw the airplane turn final for runway 34, then make a 360 degree turn to avoid another airplane that took off on runway 16. He watched the accident airplane turn downwind below airport elevation and realized the pilot was in trouble. The airplane then turned left base "far below airport elevation...attempted to climb...stalled and nosed into the ground."

Numerous witnesses saw the airplane strike powerlines. Witness #4 said "the engines were sputtering, then quit." Witness #13 heard an engine "cut out." Witness #14 said "it didn't sound like an engine was running." Witness #16 said the airplane "seemed to be stalling out engine power loss" (sic). Another witness, who had just turned south on Bluff Street, saw the airplane hit the powerlines and crash in front of his car. He said the front propeller "was barely turning."

PERSONNEL INFORMATION

The pilot was a retired FAA aviation safety inspector. He held Convair 240/340/440 and DeHaviland DHC-4 type ratings at the airline transport pilot level, and Boeing 707/720, Douglas DC-3, and North American B-25 type ratings at the commercial pilot level. His most recent logbook contained entries from April 15, 1994, to August 14, 2001. The only Cessna 337 entries in the logbook were made on February 8, 2001, when he ferried N337PM from St. George to Mesquite (0.8 hours), a local test flight on March 6, 2001 (1.0 hours), and a ferry flight from Broomfield, Colorado, to St. George (3.2 hours) on April 25. His wife stated, however, that he had flown the O-2 (the military's version of the Cessna 337) extensively when he served in the U.S. Air Force and Air Force Reserves.

AIRCRAFT INFORMATION

N337PM (s/n 337-0565), formerly N5465S and C-FFIK, was manufactured by the Cessna Aircraft Company in November 1966. During its last annual inspection on April 24, 1999, two Continental IO-360 factory remanufactured engines were installed --- a -C5B (s/n 060692-R) in the front, and a -D5B (s/n 063044-R) in the rear. The engines were remanufactured on March 27 and April 1, 1999, respectively. Two McCauley 2-blade, all metal, full feathering, constant speed propellers (m/n D2AF34C) were also installed --- a -61 (s/n 781640) in the front, and a -59 (s/n 725730) in the rear. At the time of these installations, the Hobbs meter read 283.4 hours, and the estimated total time on the airframe was 1,760.8 hours. According to the logbook entry, "Total time estimate only, no logs present before Jan. 16, 1987. Time transferred from logs of C-FFIK now changed to N337PM, 1,760.8 hrs." The Hobbs meter was recovered from the wreckage. The faceplate was missing but using a ruler for alignment, a reading of 428.85 was noted.

METEOROLOGICAL INFORMATION

The following pertinent METAR (Aviation Routine Weather Report) was recorded at the St. George Municipal Airport on the day of the accident at 1615:

Wind, 230 degrees at 3 knots; visibility, 10 statute miles; sky condition, clear; temperature, 37 degrees C. (98 degrees F.); dew point, 1 degree C. (34 degrees F.); altimeter setting, 30.00 inches of mercury.

AERODROME INFORMATION

St. George Municipal Airport (SGU) is located one mile west of the city of St. George. It is situated on top of a mesa at an elevation of 2,941 feet msl. It has one runway: 16-34, 6,606 ft. x 100 ft., asphalt.

WRECKAGE AND IMPACT INFORMATION

The on-scene investigation commenced on September 25 and terminated on September 27, 2001.

According to a spokesman for the St. George Water and Power Company, the airplane struck and severed two lines that crossed South Bluff Street: one was a phase line carrying 7,620 volts, and the other was a neutral line. Both lines were described as being 1 odd ACST (aluminum conduit steel reinforced). Each line consisted of 7 woven strands of wire about 7/16-inch in diameter. The lines spanned the street and were supported by 40-foot poles approximately 400 feet apart. The airplane struck the lines where the droop was about 38 feet above the pavement. Witnesses said that when the phase line dropped to the ground, there was considerable electrical arcing, breaking off large chunks of concrete from the sidewalk.

The airplane came to rest on the west shoulder across from 55 S. Bluff Street (Utah Highway 18) at its intersection with Tabernacle Street, on a magnetic heading of 330 degrees. The fuselage was in the gutter. The left wing tip was bent up and was resting against an embankment hill. The left wing was also bent up about 3 feet from the tip and rested on the pavement. The extended landing gear were torn off. The flaps were retracted as measured by the flap actuator. Part of the front engine cowling was knocked off, exposing the engine that was partially separated from the firewall. The propeller assembly was fractured at the crankshaft. The rear engine and propeller were undamaged. The cabin floor was crushed upward and the roof was collapsed. The mixture controls were in the FULL RICH position, the propeller controls were in the LOW PITCH/HIGH RPM position, the front and rear engine throttles were in the midrange and slightly aft of midrange positions, respectively. Both auxiliary boost pumps were OFF. The airplane was lifted onto a flatbed truck and transported to an Aero West Jet Center hangar at the airport where, on September 26, it was examined in greater detail.

During the on-site examination of the cockpit, neither fuel selector valve handle was found in the wreckage. Later, however, an Aero West Jet Center employee turned in a fuel selector valve handle he said he found in the dirt at the accident site after the wreckage had been removed. Aero West Jet Center personnel were asked the whereabouts of the other fuel selector valve handle. A search was made of several boxes of items that had previously been removed from N337PM. The other fuel selector valve handle could not be found. The other handle was positioned on the stubs of the selector valves and, using the nomenclature plate from an exemplar Cessna 337, it was determined that the right wing fuel selector handle was positioned between the RIGHT MAIN and the FUEL OFF REAR ENGINE positions, and the left wing fuel selector handle was positioned between the RIGHT MAIN X-FEED and the FUEL OFF FRONT ENGINE positions. Since the fuel selector valve cables may have been stretched when the airplane was lifted onto the salvage truck, the tops of both wings were cut open at the wing roots to expose the fuel selector valves. According to the Cessna 337 fuel system schematic, the left and right fuel selector valves were slightly misaligned from being centered on the left and right main tanks, respectively.

According to the Cessna Aircraft Company, the inboard tanks on the 300 and 400 series airplanes are the auxiliary tanks. The main tanks are the outboard tanks. On the Cessna 337B, each auxiliary tank has a 15 gallon capacity, and each main tank has a 40 gallon capacity. On September 27, the fuel tanks were drained. Each auxiliary (inboard) tank filled three 5-gallon buckets. Approximately 3 ounces of fuel were drained from the left main (outboard) sump. No fuel drained from the right main sump.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy (R200101267) was performed on the pilot by the Utah State Medical Examiner's Office in Salt Lake City. Toxicology screens were also performed by the Utah State Medical Examiner's Office and FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. According to both reports, no carbon monoxide, cyanide, or ethanol were detected, but Oxymetazoline, a nasal decongestant, was detected in the urine.

ADDITIONAL INFORMATION

In addition to the Federal Aviation Administration, parties to the investigation included the Cessna Aircraft Company.

The wreckage was released to the operator on September 27, 2001.

NTSB Probable Cause

total loss of engine power on both engines due to fuel starvation and the pilot's inability to access the available fuel supply. Contributing factors were the pilot's inadequate supervision of the refueling operation, and his intentional operation of the airplane with known deficiencies in equipment (no fuel selector valve handles or placards installed).