Date & Time:
Sep 7, 1984 at 2110 LT
Type of aircraft:
Cessna 402
Registration:
N89PB
Flight Phase:
Takeoff (climb)
Flight Type:
Scheduled Revenue Flight
Survivors:
Yes
Schedule:
Naples - Tampa
MSN:
402C-0650
YOM:
1982
Country:
United States of America
Region:
North America
Crew on board:
1
Crew fatalities:
0
Pax on board:
5
Pax fatalities:
1
Other fatalities:
0
Total fatalities:
1
Captain / Total hours on type:
412
Aircraft flight hours:
1495
Circumstances:
Shortly after takeoff, both engines lost power and a wheels up landing was made in an open field. The aircraft was destroyed by impact and fire. An investigation revealed that the aircraft had been refuel with Jet-A fuel rather than 100 low lead avgas. The lineman had inadvertently used the Jet-A fuel truck which was identical to the Avgas truck except for a decal, appx 4' by 16', which identified the type of fuel. The lineman stated that his training consisted of approximately 30 minutes of reading the company maintenance manual on how to refuel the different company aircraft, then was given on-the-job training for a brief time. When he went to refuel N89PB prior to the accident flight, he went to the parking space where the Avgas truck was normally parked, but on that occasion, the Jet-A fuel truck was there.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: climb - to cruise
Findings
1. (c) fluid, fuel grade - improper
2. (c) maintenance, service of aircraft/equipment - improper - ground personnel
3. (f) habit interference - ground personnel
4. (f) inadequate surveillance, inadequate procedure - company/operator mgmt
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Occurrence #2: forced landing
Phase of operation: landing - flare/touchdown
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Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
5. Terrain condition - rough/uneven
6. Wheels up landing - performed - pilot in command
Phase of operation: climb - to cruise
Findings
1. (c) fluid, fuel grade - improper
2. (c) maintenance, service of aircraft/equipment - improper - ground personnel
3. (f) habit interference - ground personnel
4. (f) inadequate surveillance, inadequate procedure - company/operator mgmt
----------
Occurrence #2: forced landing
Phase of operation: landing - flare/touchdown
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
5. Terrain condition - rough/uneven
6. Wheels up landing - performed - pilot in command
Final Report:
N89PB.pdf89.37 KB