Crash of a Cessna 402B in St Petersburg

Date & Time: Oct 18, 2017 at 1545 LT
Type of aircraft:
Operator:
Registration:
N900CR
Survivors:
Yes
Site:
Schedule:
Tampa – Sarasota
MSN:
402B-1356
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
654
Captain / Total hours on type:
38.00
Aircraft flight hours:
8971
Circumstances:
The pilot departed on the non-scheduled passenger flight with one passenger onboard; the flight was the 3rd leg of a 4-leg trip. About 13 minutes after departure, he advised air traffic control that the airplane was “fuel critical” and requested vectors to the nearest airport, which was about 7 miles away. Both engines subsequently lost total power and the pilot performed a forced landing on a street about 2 miles from the airport, during which the airplane collided with two vehicles. Examination of the airplane revealed substantial damage to the fuel tanks, with evidence of a small fire near the left wingtip fuel tank. Fuel consumption calculations revealed that the airplane would have used about 100 gallons of fuel since its most recent refueling, which was the capacity of the main (wingtip) tanks. Both fuel selectors were found in their respective main tank positions. Given the available information, it is likely that the pilot exhausted all the fuel in the main fuel tanks and starved the engines of fuel. Although the total amount of fuel on board at the start of the flight could not be determined, had all tanks been full, the airplane would have had about 63 gallons remaining in the two auxiliary tanks at the time of the accident. The auxiliary fuel tanks were breached during the accident and quantity of fuel they contained was not determined. Examination of the engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause:
The pilot's mismanagement of the onboard fuel, which resulted in fuel starvation, a total loss of power to both engines, and a subsequent forced landing.
Final Report:

Crash of a Cessna 402B in Nantucket

Date & Time: Sep 13, 2017 at 0723 LT
Type of aircraft:
Registration:
N836GW
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nantucket – Hyannis
MSN:
402B-1242
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1500
Captain / Total hours on type:
1100.00
Aircraft flight hours:
4928
Circumstances:
The commercial pilot stated that, shortly after taking off for a cross-country, personal flight and while accelerating, he noticed high airplane nose-down control forces and that the airplane became increasingly difficult to control. He used manual trim to attempt to trim out the control forces and verified that the autopilot was not engaged; however, the nose-down tendency continued, and the pilot had trouble maintaining altitude. During the subsequent emergency landing, the airframe sustained substantial damage. Postaccident examination of the airplane revealed that the elevator trim push rod assembly was separated from the elevator trim tab actuator, and the end of the elevator trim push rod assembly was found wedged against the elevator's main spar. The elevator trim indicator in the cockpit was found in the nose-up stop position; however, the elevator trim tab was deflected 24° trailing edge up/airplane nose down (the maximum airplane nose-down setting is 6°). A drilled bolt was recovered from inside the right elevator; however, the associated washer, castellated nut, and cotter pin were not found. Examination of the bolt revealed that the threads were damaged and that the bolt hole on one of the clevis yoke halves exhibited deformation, consistent with the bolt separating. About 2 weeks before the accident, the pilot flew the airplane to a maintenance facility for an annual inspection. At that time, Airworthiness Directive (AD) 2016-07-24, which required installation of new hardware at both ends of the pushrod for the elevator trim tab, was overdue. While the airplane was in for the annual inspection, AD 2016-07-24 was superseded by AD 2016-17-08, which also required the installation of new hardware. The ADs were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of airplane control. While in for the annual inspection, the airplane was stripped and painted, which would have required removal of the right elevator. Although the repair station personnel indicated that they did not disconnect the elevator trim pushrod from the elevator trim tab actuator when they painted the airplane, photographs taken of the airplane while it was undergoing inspection and painting revealed that the pushrod likely had been disconnected. The repair station owner reported that he reinstalled the right elevator and the elevator trim pushrod after the airplane was painted; however, he did not replace the hardware at either end of the pushrod as required by the ADs. Subsequently, the airplane was approved for return to service. After the annual inspection, no work, repairs, or adjustments were made to the elevator trim system. The airplane had accrued about 58 hours since the annual inspection at the time of the accident. Although reusing the self-locking nut might have resulted in it coming off by itself, the cotter pin should have prevented this from happening. Therefore, although the castellated self-locking nut, washer, and cotter pin normally used to secure the elevator trim pushrod at the elevator trim tab actuator were not found, given the evidence it is likely that the hardware, which was not the required hardware, was not properly secured at installation, which allowed it to separate in flight. It is also likely that the pushrod assembly then moved aft and jammed in a position well past the maximum nose-down trim setting, which rendered controlled flight impossible.
Probable cause:
The separation of the pushrod from the elevator trim tab actuator, which rendered controlled flight impossible. Contributing to the separation of the pushrod was the failure of maintenance personnel to properly secure it to the elevator trim tab actuator.
Final Report:

Crash of a Cessna 402C in Virgin Gorda

Date & Time: Feb 11, 2017 at 2004 LT
Type of aircraft:
Registration:
N603AB
Survivors:
Yes
Schedule:
Charlotte Amalie – Virgin Gorda
MSN:
402C-0603
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5458
Captain / Total hours on type:
809.00
Circumstances:
The aircraft was flying from St Thomas in the US Virgin Islands to Virgin Gorda (VIJ) in the British Virgin Islands. There were eight passengers on board, together with the pilot. It was the pilot’s eleventh flight of the day, and his fourth flight to Virgin Gorda. All these flights were short, with the longest flight being about 40 minutes duration and the shortest just a few minutes. The flight from St Thomas to Virgin Gorda took 35 minutes. The weather in Virgin Gorda was excellent with a light easterly wind and little cloud. The pilot commenced his approach to Virgin Gorda using his usual turning and configuration points. The aircraft touched down normally on runway 03 and the pilot retracted the flaps before applying the brakes. The brakes responded, although the pilot commented that the right brake did not seem to respond as positively as he expected. The pilot reapplied the brakes but the left brake pedal “flopped to the floor”. Judging he had insufficient room to abort the landing, the pilot continued to pump the brakes which he did not consider to be responding. He shut down the engines before the aircraft left the paved surface, struck signage and then a low wall before coming to rest on a bank. The pilot vacated the aircraft through the side window and then opened the main door to allow the passengers to exit the aircraft. None of the occupants was injured. The aircraft was extensively damaged.
Probable cause:
The aircraft landed at Virgin Gorda in conditions (of weight, altitude, temperature and surface condition) where the landing distance required was very close to the landing distance available and without the required safety margin. Hence, when the performance of the brakes was not as expected, probably due to debris in the braking system, the aircraft could not be stopped on the runway. Analysis of the maintenance state of the aircraft involved in this accident indicated that the maintenance capability, processes and planning of its operator were not consistent with the standards expected in conducting international passenger charter services. This appeared also to be the case for the operational procedures and data management.
Final Report: