Las Cruces

According to the line service technician who worked for the fixed-base operator (FBO), before taking off for the air ambulance flight with two medical crewmembers and one patient onboard, the pilot verbally asked him to add 40 gallons of fuel to the airplane, but the pilot did not specify the type of fuel. The line service technician drove a fuel truck to the front of the airplane and added 20 gallons of fuel to each of the multiengine airplane's wing tanks. The pilot was present during the refueling and helped the line service technician replace both fuel caps. Shortly after takeoff, a medical crewmember called the company medical dispatcher and reported that they were returning to the airport because smoke was coming from the right engine. Two witnesses reported seeing smoke from the airplane Several other witnesses reported seeing or hearing the impact and then immediately seeing smoke or flames. On-scene evidence showed the airplane was generally eastbound and upright when it impacted terrain. A postimpact fire immediately ensued and consumed most of the airplane. Investigators who arrived at the scene the day following the accident reported clearly detecting the smell of jet fuel. The airplane, which was equipped with two reciprocating engines, should have been serviced with aviation gasoline, and this was noted on labels near the fuel filler ports, which stated "AVGAS ONLY." However, a postaccident review of refueling records, statements from the line service technician, and the on-scene smell of jet fuel are consistent with the airplane having been misfueled with Jet A fuel instead of the required 100LL aviation gasoline, which can result in detonation in the engine and the subsequent loss of engine power. Postaccident examination of the engines revealed internal damage and evidence of detonation. It was the joint responsibility of the line technician and pilot to ensure that the airplane was filled with aviation fuel instead of jet fuel and their failure to do so led to the detonation in the engine and the subsequent loss of power during initial climb.In accordance with voluntary industry standards, the FBO's jet fuel truck should have been equipped with an oversized fuel nozzle; instead, it was equipped with a smaller diameter nozzle, which allowed the nozzle to be inserted into the smaller fuel filler ports on airplanes that used aviation gasoline. The FBO's use of a small nozzle allowed it to be inserted in the accident airplane's filler port and for jet fuel to be inadvertently added to the airplane.

The non-instrument rated private pilot departed Montrose, Colorado, southbound in a Cessna 421B. According to radar data, the airplane climbed from 14,300 to 16,600 feet msl at a rate of 1,792 fpm. The data shows that 19 seconds later, the airplane lost 4,000 feet of altitude, or descended at a rate of 12,631 fpm. The airplane then climbed back to 13,300 feet msl at a rate of 1,448 fpm, and then disappeared from radar. The airplane crashed in snow covered mountainous terrain. Snowmobilers, who were in the vicinity of the impact site at the time of the accident, said that snow showers made visibility less than 1/2 sm. A pilot departing Telluride Regional Airport (located 33 nm at 045 degrees from the crash site), on a heading of 300 degrees, at approximately 1015 said that it was clear right over Telluride. He said that as he climbed out, he got into weather at 12,000 feet msl, and didn't break out until 22,000 feet msl. He also said that he experienced no icing or turbulence during his climb out.

The pilot, a heart transplant surgeon, was advised of a donor in Las Cruces, NM. He and a physician's assistant were to fly to Las Cruces, retrieve the donor heart, and return to Albuquerque, where the transplant was to be performed. The pilot obtained a weather briefing (VMC was forecast) and filed an IFR flight plan. He fueled the jet aircraft to capacity and took off into a dark, clear, moonless night towards open, flat terrain with few ground lights. The aircraft crashed seconds later. It impacted the ground in a left wing/nose slightly low attitude at high speed. There was no evidence of preimpact failure/malfunction of the airframe, engines, instruments, or controls. The pilot had been awake for 22 hours with little or no rest. He was not current for night flight. His IFR currency could not be determined. Both occupants were killed.

During the night cross country flight at FL250, the pilot elected to leave the cockpit area and move to the rear of the aircraft to attend to physiological needs. Although oxygen was available in the cockpit, supplemental oxygen was not available in the rear. The aircraft was operated with a known pressurization system deficiency which limited the airplane to flight to 17,000 feet msl while maintaining a cabin altitude of 10,000 feet. After 2 hours and 10 minutes, atc declared the flight to be 'no radio'. At 3 hours and 57 minutes after departure, the airplane was plotted on radar in a descending left turn to ground impact. Fuel starvation resulted in power loss to the left engine. Propeller signatures indicated power on the right propeller at impact. The pilot's body was found in the aft cabin area on the aft cabin bulkhead.