Cessna 402

The pilot’s improper preflight planning and fuel management, which resulted in a total loss of power in both engines due to fuel exhaustion.

Breakdown in communication during the planning and execution of an unapproved procedure has been determined to be the probable cause of this accident.
Other contributing factors:
- Use of an unapproved procedure to aid in a maneuver that was critical,
- Too many persons were planning the maneuver and not coordinating their actions,
- Failure of planners of the maneuver to verify whether participants were in the right position,
- Inexperienced persons used in the execution of a maneuver that was not approved,
- Vehicle parked to close to the side of the runway,
- Vehicle left with engine running while parked near the runway.

The failure of the seal of the balance tube on the left engine intake manifold, causing a loss of manifold pressure and then a loss of engine power.
Contributing Factor:
- Discrepancies found with the quality control of the maintenance services performed on the aircraft,
- The non-assertive decisions taken during the flight when the emergency occurred.

The pilot did not maintain minimum controllable airspeed while on final approach with a partial loss of power in the right engine, which resulted in a loss of control. Contributing to the accident was the partial loss of engine power in the right engine due to the improperly installed o-rings in the engine’s throttle and control assembly.

The following findings were identified:
1. Acklins Blue Air Charter was advertising and operating as a Bahamas air taxi operator without having undergone the certification process in contravention of Bahamas Civil Aviation (Safety) Regulations Schedule 12.
2. The airplane was issued a Certificate of Airworthiness on May 19, 2010, by the Bahamas Flight Standards Inspectorate, and was being operated by Acklins Blue Air Charter.
3. The Cessna 402C aircraft is classified in the performance Group C. This requires rapid feathering of the propeller of a failed engine and the raising of flap and the landing gear in order to achieve maximum climb performance.
4. The airplane maintenance records were not located; therefore, no determination could be made whether the airplane was being maintained in accordance with Bahamas Civil Aviation Regulations.
5. The 12,000 hour pilot and second pilot were not qualified to operate in Bahamas commercial air taxi operations.
6. No determination could be made whether the pilot or second pilot had completed required training and had accomplished a satisfactory recurrent flight check of their flying ability as required by CASR Schedule 12 and 14 for aircraft operating in commercial air transportation as well as the stipulation by the insurance policy.
7. Post-accident weight and balance calculations indicate the airplane was being operated approximately 523 pounds over maximum certificated takeoff weight (6,850 lb)
8. The pilot was advised by an air traffic controller that white smoke was trailing the left engine during takeoff; the pilot did not declare an emergency or advise the controller of any engine failure or mechanical abnormality.
9. The airplane's left engine could not produce rated shaft horsepower during takeoff.
10. Several factors contributing to the degradation of the airplane's performance and its inability to maintain flight include the wind-milling propeller, the pilot's intentional initiation of a steep turn to return to the departure airport, and his intentional lowering of the landing gear during the turn to return.
11. While turning to return, the airplane stalled, pitched nose down, and impacted in a lake.
12. The search and rescue efforts were timely and appropriate; however, the lack of accurate information on the pilot submitted flight plan delayed recovery of all victims.
13. The left propeller was not feathered.
14. The No. 2 cylinder of the left engine failed due to fatigue that originated in the root of the cylinder head thread that was engaged with the first thread on the barrel.
15. Post-accident inspection of the cockpit revealed several switches for the right engine were secured; however, no determination could be made when the switches were placed / moved in those positions.
16. No evidence of failure of the airplane's structures or flight control system contributed to the accident.
17. Existing regulations did not require the aircraft to be fitted with flight recorders. The lack of any recorded data about the aircraft's performance or the flight crew conversations deprived the investigation team of essential factual information.
18. Current Civil Aviation Department personnel and budget resources may not be sufficient to ensure that the quality of surveillance for certified as well as uncertified air carrier operations will improve.
19. Airside access procedures are inadequate at Fixed Base Operators. Access to the secure airside occurring without any check of individuals to challenge whether they have a legitimate reason for accessing the secure airside. FBO door to access airside is not secured or locked continuously; persons observed walking in and out without being challenged.
20. Flight Plan Forms are being accepted and transmitted to ATC with incomplete information. This information is vital for search and rescue purposes.
21. Weather was not a factor in the accident.
22. ATC was not a factor in the accident.
23. Currently flight plans for private flights are only required for international operations.
24. The pilot was aware of discrepancy associated with the manifold pressure reading of the left engine prior to takeoff. This discrepancy was brought to his attention by a client from the flight immediately preceding the accident flight.
25. The exact center of gravity of the accident airplane could not be calculated accurately as no indication of what seat each passenger occupied in the airplane and no indication of where luggage or equipment were placed on the aircraft could be determined. However, due to the exceedance of weight limits the aircraft was already outside the allowable center of gravity envelope developed by the manufacturer.
26. The pilot had insufficient time to prepare for the approach to runway 27 before beginning the approach. The airplane pitched up quickly into a stall, after extension of gear, recovery before ground impact was unlikely once the stall began.
27. Post accident inspection did not reveal any mechanical evidence or problems with the right hand engine.
28. The pilot's decision to return to the airfield was reasonable. Once the aircraft began to lose height a return to the airfield became impractical and a forced landing in the direction of flight should have been attempted.
29. The right propeller was never recovered from the lake.
The following causal factors were identified:
1. The left engine suffered a mechanical failure of the #2 cylinder, and therefore could not produce rated shaft horsepower. No indication of total loss of power with the left engine reported.
2. Right Engine electrical and engine control switches were found in the “OFF” position, therefore the aircraft was incapable of climbing on the power of one engine alone.
3. The excess weight above the maximum weight allowed for takeoff may have been an important factor in the aircraft's inability to gain adequate altitude after takeoff.
4. The pilot secured the right engine which was mechanically capable of producing power resulting in a total loss of thrust. He then sometime thereafter initiated a steep turn with gear down and the left engine already not developing sufficient shaft horsepower to sustain lift.
5. The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the left.