Cessna 402

The pilot’s improper fuel management, which resulted in a loss of engine power during an instrument landing due to fuel exhaustion.

It is believed that the loss of control and the subsequent crash was the consequence of an engine power loss following the failure of the turbo.

Controlled flight into terrain.

A loss of aircraft control due to spatial disorientation.

The investigation identified the following primary causal factor:
The two aircraft collided because their respective pilots either did not see the other aircraft, or did not see it in time to take effective avoiding action.
The investigation identified the following contributory factors:
1. The likelihood that the crew of G-EYES would see G-BOLZ in time to carry out effective avoiding action was reduced by the small size of G-BOLZ, its position relative to G-EYES and the high rate of closure between the aircraft.
2. Insufficient or inaccurate information was provided to the pilots, which did not assist them in fulfilling their duty to take all possible measures to avoid collisions with other aircraft.
3. The Aerodrome Controller’s sequencing plan, which was based on an incomplete understanding of the nature of G-EYES’ flight, was unlikely to have been successful. By the time the risk of a collision was identified, it was too late to devise an effective method of resolving the situation.
4. There were no effective measures in place to give G-EYES priority over traffic in the visual circuit

A partial loss of engine power due to fuel starvation. Contributing to the accident was the pilot’s decision to add only a limited amount of fuel prior to the flight, and the fuel selector valve placards' inaccurate depiction of the airplane fuel tank configuration.

The investigation determines that the probable causes of this accident to be the following;
• Substandard maintenance that was performed. (Due to the improper flange on the hydraulic line, the hydraulic line came loose from its housing and depleted the fluid from the hydraulic
reservoir).
• Failure of the back up emergency blow down bottle system. It has been determined from inspection that the cable that connects the emergency blow down bottle system in the nose well of the aircraft to the T-handle in the cockpit, exhibited excessive play. Therefore even though the cable was pulled all the way to its fullest extent, it did not allow movement of the pin that would have provided activation of the system. Annual inspection report completed in December 2005 revealed that the portion of the Annual Inspection that required inspection of the emergency blow down bottle was not signed off by the mechanic as having been accomplished. However, the aircraft was returned to service with this discrepancy outstanding.
• Pilot’s lack of qualification and unfamiliarity with this aircraft, its systems and emergency procedures. ( Evidence of falsification of qualification and time requirement exists in pilot’s logbook).
• Pilot’s poor decision making and impaired judgement. (Possibility of impaired judgement due to pilot fatigue).
• Pilot’s failure in assessing the severity of his situation.
• Pilot’s failure to notify ATC of his problem. (Problem was discovered 20 miles prior to the accident).
• Pilot’s failure to properly assess the conditions for landing and maintain vigilant situational awareness while manoeuvring the aircraft after landing. (From post accident inspection, it was noted that the flaps were not extended for the landing. Had it been extended the aircraft glide path as well as the distance required for roll out after landing may have been greatly decreased).
• Pilot’s failure to take immediate action once he realized his predicament. (Pilot stated that after the propeller made contact with the ground, he decided to apply power and go around, but it was too late. Failure to act also can be attributed to possible pilot fatigue as (pilot was out all day shopping and then decided to leave at such a late hour) well as pilot’s unfamiliarity with aircraft systems and performance capabilities).
• Pilot’s failure to request Emergency Service Assistance. Had this service been requested in a timely manner, preparations could have been made to prevent the fire from spreading to the degree in which it did.