All Puerto Rico

The non-Spanish speaking commercial pilot was preparing for a Title 14, CFR Part 135 on-demand charter flight in a twin-engine airplane with gasoline engines. A non-English speaking fuel truck operator inadvertently serviced the accident airplane with 120 gallons of Jet-A turbine fuel. In the pilot's written statement he reported that just after takeoff, with six passengers aboard, both engines began to lose power, and the airplane subsequently descended and collided with tree-covered terrain at the departure end of the runway. An on-site examination of the fuel vender's Jet-A fuel truck disclosed that the dispensing nozzle installed on the truck was the same nozzle as a typical gasoline nozzle. An examination of the accident airplane's fuel caps and fueling ports disclosed that the accident airplane was equipped with round, fuel tank inlet restrictors, that would prevent fueling from a jet fuel nozzle of the appropriate size, but the fueling ports were not placarded with the required statement indicating that only gasoline (av-gas) should be used.

On September 29, 2004, about 1859, Atlantic standard time, the accident airplane, N902GD, operating as an "on demand" air taxi flight, transporting bank financial documents, departed
Mayaguez, Puerto Rico, and was later reported as not having arrived at its destination. Search and rescue assets later discovered airplane related debris, specific to the missing airplane, floating in the Atlantic Ocean, in the vicinity of geographic position 18 degrees 29 minutes north latitude, 066 degrees 27 minutes west longitude. The NTSB evaluated radar and weather data, and radar track data for the flight showed that after departure the accident airplane climbed to 1,700 feet, and then descended to 1,300 feet at 1840. From 1840 to 1850, the radar data indicated that the flight was proceeding east along the northern coast of Puerto Rico, at an altitude of 1,100 feet. About 1855, the data showed that the airplane climbed to 1,400 feet, and about 1856, it descended to about 1,000 feet. About 1858, the airplane descended to 800 feet, and then to 600 feet, before disappearing from radar at 18:59:18. Weather data showed that a weak upper air trough, a moist low level southeasterly flow and associated showers and thunderstorms had formed over Puerto Rico during the time of the accident flight. The weather data showed that at departure visual meteorological conditions existed, but doppler weather radar data showed that a 50 dBz (level 5) rain shower was positioned about 3 to 5 miles off the airplane's right wing from 1837 to 1838, and from 1855 to 1901 there was a level 4-5 (45-50 dBZ) rain shower along the accident airplane's track, and the radar track data along with the doppler weather radar data was consistent with the flight having penetrated the rain shower corresponding to the time radar contact with the flight was lost. The NTSB Weather Group Chairman's Report has been included as an attachment to the factual report.

Flight 5401 departed Mayagüez, Puerto Rico, for San Juan about 14:15. The captain was the nonflying pilot for the flight, and the first officer was the flying pilot. The takeoff, climb, and en route portions of the flight were uneventful. At 14:37, as the flight approached the San Juan traffic area, the ATIS reported that winds were 060 degrees at 17 knots and gusting at 23 knots. Shortly thereafter, the captain briefed a Vref (the minimum approach airspeed in the landing configuration before the airplane reaches the runway threshold) of 95 knots and told the first officer to "stand by for winds." At 14:43 SJU Terminal Radar Approach Control cautioned the pilots of possible wake turbulence from a preceding Boeing. The captain told the first officer to slow down to about 140 kts. At 14:46, the local controller cleared the airplane to land on runway 08. The first officer turned the airplane left toward runway 08 and transitioned to the visual approach slope indicator. At 14:49, the captain stated, "you better keep that nose down or get some power up because you're gonna balloon." The airplane descended below the glideslope, causing a GPWS "glideslope" alert. The airplane was about 45 feet above ground level and traveling at 110 knots indicated airspeed when it crossed the runway 08 threshold. After the airplane crossed the runway threshold, the captain stated, "power in a little bit, don't pull the nose up, don't pull the nose up." At 14:49:39, the captain stated, "you're ballooning," and the first officer replied, "all right." The airplane touched down for the first time about 14:49:41 and about 1,600 feet beyond the runway 08 threshold with vertical and lateral loads of about 1.3 Gs and -0.10 G, respectively. Upon touchdown the captain stated, "get the power," and, 1 second later, "my aircraft." The first officer responded, "your airplane." The airplane had skipped to an altitude of about 4 feet and touched down again two seconds later about 2,200 feet beyond the runway 08 threshold. The airplane then pitched up to an angle of 9° while climbing to an altitude of 37 feet and the engine torque increased from 10 to 43 percent. About 14:49:49, the pitch angle decreased to -3°, and the engine torque started to decrease to 20 percent with the pitch angle decreasing to -10°. The airplane touched down a third time about 14:49:51 at a bank angle of 7° left wing down and about 3,300 feet beyond the runway 08 threshold and with vertical and lateral loads of about 5 Gs and 0.85 G. The ATR pitched up again to 24 feet and landed a fourth time about 14:49:56 (about 15 seconds after the initial touchdown) and about 4,000 feet beyond the runway 08 threshold. This time the airplane pitched down to -7° and that it was banked 29° left wing down. The airplane came to a complete stop on a grassy area about 217 feet left of the runway centerline and about 4,317 feet beyond the runway threshold.

While on descent, the pilot reported that the airplane's left engine had lost power. He secured the left engine, and when he added power to the right engine, he believed it was not developing full power. He could not maintain altitude and elected to perform a forced landing in an open field. The airplane touched down long and with excessive speed on to the field striking trees, power lines and collided with the ground. A maintenance action entry in the aircraft's maintenance logbook indicate that the wing tip fuel tanks had the drain valve o-rings removed and replaced on the day before the accident. The maintenance entry states wing tip tanks were empty. The pilot stated he elected not to fuel either one of the wing tip tanks, due to the fact that maintenance was performed on them and did not select fuel from the wing tip tanks on the day of the accident. Excerpts from Airworthiness Directive (AD) 83-23-1, which is applicable to the accident airplane, states "This is a tip-tanked aircraft. Tip-tanks are to be filled first-used last. Before take-off check both main and tip-tank contents". AD 83-23-1 instructs to place a placard in clear view of the pilot on the instrument panel referring to the protocol of fueling and takeoff processors with regards to fuel tank contents. The mechanic who perform the maintenance to the wing tip tanks stated the placard was installed and in plain view of the pilot. The pilot stated he fueled the airplane with 50 gallons of aviation gasoline for a total of 90 gallons in both main tanks for the flight to Culebra from Ponce. The pilot went on to state prior to the return flight to Ponce from Culebra he checked his fuel quantity, which indicated he had 35 gallons in each main fuel tank for a total of 70 gallons aboard the airplane before departure. Fuel samples from both the FAA and the port authorities from the facility where the airplane was fueled for the flight showed no contamination as per the FAA Inspector statement.

The crew departed Roosevelt Roads NAS on a local training flight. In the evening, while returning the to NAS, the crew encountered poor weather conditions with low clouds, limited visibility and rain falls. While descending at low height, the crew suffered a loss of situational awareness and failed to respond to obstacle warnings. The four engine aircraft collided with trees and crashed on the top of Mt Perucho. The aircraft disintegrated on impact and all 10 crew members were killed.

The flight departed VFR, and when near the destination airport, was advised by air traffic control to hold VFR over the "plaza" and to make left 360 degree orbits. Several witnesses reported light rain was occurring at the time of the accident; there was no lightning or thunder. One witness located where the airplane came to rest reported observing the airplane emerge from the base of the clouds in a 45-degree left wing low and 20 degrees nose low attitude. He momentarily lost sight of the airplane but then noted it rolled to a wings level attitude. He also reported hearing the engine(s) "cutting in an out." Another witness located approximately 1/4 mile north of the accident site observed the airplane flying eastbound beneath the clouds in a right wing and nose low attitude, he also reported hearing the engine(s) sounding like they were "cutting in and out." A pilot-rated witness located an estimated 1,000 feet from where the airplane came to rest estimated that the ceiling was at 300 feet and there was light drizzle. He observed the airplane in a 45-degree angle of bank to the right and in a slight nose low attitude. He stated that the airplane continued in that attitude before he lost sight of the airplane at 250 feet. The airplane impacted trees then a concrete wall while in a nose and right wing low attitude. The airplane then traveled through automobile hoists/lifts which were covered by corrugated metal, and came to rest adjacent to a building of an automobile facility. Impact and a post crash fire destroyed the airplane, along with a building and several vehicles parked at the facility. Examination of the airplane revealed the flaps were symmetrically retracted and landing gears were retracted. No evidence of preimpact failure or malfunction was noted to the flight controls. Examination of the engines revealed no evidence of preimpact failure or malfunction; impact and fire damage precluded testing of several engine accessories from both engines. Examination of the propellers revealed no evidence of preimpact failure or malfunction. Parallel slash marks were noted in several of the corrugated metal panels that covered the hoists/lifts, the slashes were noted 25 and 21 inches between them. According to the airplane manufacturer, the 25 inch distance between the propeller slashes corresponds to an airspeed of 123 knots. Additionally, the power-off stall speed at the airplanes calculated weight with the flaps retracted and 48 degree angle of bank was calculated to be 122 knots. Review of NTSB plotted radar data revealed that the pilot performed one 360-degree orbit to the left with varying angles of left bank and while flying initially at 1,300 feet, climbing to near 1,500 feet, then descending to approximately 800 feet. The airplane continued in the left turn and between 1502:10 and 1502:27, the calibrated airspeed decreased from 160 to 100 knots. At 1502:27, the bank angle was 48 degrees, and the angle of attack was 26 degrees. Between 1502:30 and 1502:35, the true heading changed indicating a bank to the right. The last plotted altitude was 200 feet, which occurred at 1502:35. A NTSB weather study indicated that at the area and altitude the airplane was operating, NWS VIP level 1 to 2 echoes (light to moderate intensity) were noted. Additionally, the terminal aerodrome forecast (TAF) for the destination airport indicated that temporarily between 1400 and 1800 (the flight departed at approximately 1436 and the accident occurred at approximately 1503), visibility 5 miles with moderate rain showers, scattered clouds at 1,500 feet, and a broken ceiling at 3,000 feet.

The pilot was on a visual rules flight from Culebra, Puerto Rico to San Juan, Puerto Rico. No flight plan was filed and a weather briefing was not obtained. The pilot contacted San Juan Radar Approach Control 10 miles east of Fajardo, Puerto Rico and the controller stated the airplane was in radar contact 3 miles east of Fajardo airport. The pilot was instructed to enter a right downwind for runway 10 south of plaza Carolina. The pilot acknowledged the transmission and reported he was at 1,600 feet. Two minutes later the controller stated on the radio frequency, radar contact was lost. The airplane was located by ground personnel on the side of El Yunque Mountain. Review of weather data revealed a weak cold front extended over Puerto Rico. Satellite imagery at the time of the accident revealed a band of low clouds obscuring the accident site. A police helicopter pilot who attempted to reach the crash site reported instrument flight conditions. Examination of the airframe, flight controls, engine assemblies and accessories revealed no anomalies.

The flight was being handled as a VFR aircraft by air traffic control, was given a discreet transponder code, and was radar contact at an altitude of 4,500 feet. The pilot requested a VFR descent from 4,500 feet, and was cleared to "…descend unrestricted west bound." Radar and radio contact were lost at an altitude of 2,700 feet. The controller tried to re-establish radio contact with the airplane's pilot 10 times before initiating search and rescue efforts. A U.S. Coast Guard helicopter found the wreckage, using the aircraft's emergency locator transmitter. The next day a ground search for the aircraft was halted because of hazardous terrain. Search and rescue personnel had to be airlifted into the crash site to remove the victim. A police helicopter was vectored to the crash site by ATC about an 1 1/2 hours after contact was lost with the flight, and the pilot reported that he could not fly near the crash site because of fog. He reported the ceiling about 2,400 feet. The aircraft impacted in heavily wooded, mountainous terrain at the 2,700-foot level of a 3,524-foot mountain. Toxicology test showed that venlafaxine and desmethylvenlafaxine drugs were found in the pilot's blood, and the levels found were consistent with the recent ingestion of more than 10 times a normal dose of venlafaxine.

The flight crew stated that while making a missed approach after a practice instrument landing system approach, the right engine failed. The captain took control of the airplane from the copilot. The captain stated that while he performed the emergency procedures for engine failure, he noticed the left engine was not producing power. He then made a forced landing in water east of the airport. He stated that just before impact, he feathered the left propeller. The copilot stated he observed the captain activate the propeller feathering button for the left engine as he performed the emergency procedures for the right engine failure. The reason for failure of the right engine was not determined.

After departure from San Juan, the pilot of N405MN contacted the FAA San Juan Approach Control, was identified on radar by the controller, and told to climb to 7,000 feet. About 1 minute later, the pilot is told to proceed direct to St. Croix. About 4 minutes later, the pilot requested radar vectors to St. Croix, and was told to fly heading 140 degrees. Radar data showed the flight leveled at the cruise altitude of 7,000 feet at about 0444. At about 0453:36, the pilot requested a lower altitude, and was cleared to 2,000 feet. The pilot acknowledged the clearance, and no further transmissions were received from the pilot. The flight began descent from 7,000 feet at about 0454. At 0454:29, the aircraft's transponder reports the flight is at 6,500 feet. At 0454:41, the transponder reports the flight is at 5,600 feet, and at 0454:49, at 4,000 feet. At 0454:53, the transponder reports the flight is at 1,100 feet. The flight is not observed on radar after this. No other aircraft or radar returns are observed near the flight as it began it's descent. One main landing gear tire, wheel, and brake assembly; the left wing lower skin from the area above the wing flap; the left wing baggage compartment door; the right nose baggage compartment door; the cabin floor cover; and some items from the U.S. mail cargo, were recovered floating in the ocean, at points north of the last observed radar contact with the airplane, on the day of the accident and in the days after the accident. The recovered components had damage from being separated from the airplane. None of the recovered components had any fire, heat, or soot damage. The remainder of the airplane was not located and recovered. The depth of the sea in the area of the accident site was reported by the Coast Guard to be about 6,000 feet. U.S. Post Office personnel reported the flight carried 1,517 pounds of U.S. mail. No hazardous materials were in the mail. A 75-pound pouch of mail was recovered from the ocean and identified as having been placed on N405MN. The weather at the time of the accident was reported to scattered clouds with visibility 10 miles.