Individually Owned: 150,657
Corporate Owned: 137,281
San Antonio International Airport
Aircraft Accident/Incident Report
San Antonio, Texas 78216
Thursday, February 10, 1994 7:13 CST
NTSB Narrative Summary Released at Completion of Accident
SHORTLY AFTER TAKEOFF, THE PILOT REPORTED HE HAD 'A PROBLEM' AND NEEDED TO RETURN IMMEDIATELY. WITNESSES OBSERVED DARK BLACK SMOKE COMING FROM BOTH ENGINES. THE AIRPLANE COLLIDED WITH A TREE 1/2-MILE NORTHEAST OF THE RUNWAY THRESHOLD. ANALYSIS OF FUEL SAMPLES REVEALED THE PRESENCE OF APPROXIMATELY 50% JET FUEL. THE RIGHT PROPELLER WAS FOUND FEATHERED AND ENGINE DISASSEMBLY REVEALED A HOLE BURNED IN THE RIGHT ENGINE NUMBER 5 PISTON. LEFT ENGINE DISASSEMBLY REVEALED PISTON EDGES ERODED DOWN TO THE FIRST COMPRESSION RING. FUEL FILLER RESTRICTORS HAD BEEN INSTALLED IN THE AIRPLANE'S FUEL TANKS, BUT THE FUEL TRUCK DID NOT HAVE THE RESTRICTIVE MATING NOZZLE. THE FUEL TRUCK WAS OWNED BY THE FUEL VENDER AND LEASED TO THE FBO.
NTSB Probable Cause Narrative
IMPROPER SERVICING OF THE AIRPLANE WITH JET FUEL, WHICH RESULTED IN PREIGNITION AND/OR DETONATION AND SUBSEQUENT FAILURE OF PISTONS IN BOTH ENGINES. A FACTOR RELATED TO THE ACCIDENT WAS: THE LACK OF A RESTRICTIVE MATING NOZZLE ON THE REFUELING TRUCK.
Event Information
| Type of Event | Accident |
| Event Date | 2/10/1994 |
| Event Day of the Week | Thursday |
| Time of Event | 713 |
| Event Time Zone | Central Standard Time |
| Event City | SAN ANTONIO |
| Event State | TEXAS |
| Event Country | -- |
| Zipcode of the event site | 78216 |
| Event Date Year | 1994 |
| Event Date Month | 2 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | SAN ANTONIO INTERNATIONAL |
| Event Location Nearest Airport ID | SAT |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 1 |
| Degrees magnetic from airport | 310 |
| Airport Elevation | 809 |
| Weather Briefing Completeness | Full |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 716 Central Standard Time |
| Direction of event from weather observation facility (degrees) | 130 |
| Weather Observation Facility ID | SAT |
| Elevation of weather observation facility | 809 |
| Distance of event from weather observation facility (units?) | 1 |
| Time Zone of the weather observation | CST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 1200 |
| Lowest Non-Ceiling Height | 1200 |
| Sky/Lowest/Cloud Conditions | Unknown |
| Sky Condition for Lowest Ceiling | Overcast |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 7 |
| Air Temperature at event time (in degrees celsius) | -- |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 330 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 12 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | 0 |
| Intensity of Precipitation | Light |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 2 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 3 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 93 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Feb 10 1994 12:00AM |
| NTSB Notification Time | 745 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Dec 6 2000 10:40AM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N741CA |
| NTSB Number | FTW94FA082 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | Ground |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | CESSNA |
| Aircraft Model | 421C |
| Aircraft Series Identifier | 421C |
| Aircraft Serial Number | 421C-0899 |
| Certified Max Gross Weight | 7450 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 5 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | AAIP |
| Date of Last Inspection | Dec 3 1993 12:00AM |
| Airframe hours since last inspection | 18 |
| Airframe Hours | 2916 |
| ELT Installed | Yes |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | CRITICAL AIR MEDICINE, INC. |
| Aircraft Owner Street Address | 4141 KEARNEY VILLA ROAD |
| Aircraft Owner City | SAN DIEGO |
| Aircraft Owner State | CA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 92123 |
| Operator is an individual? | -- |
| Operator Name | |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | |
| Operator City | |
| Operator State | |
| Operator Country | |
| Operator Zip code | |
| Operator Code | IBUA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Positioning |
| Second Pilot on Board | No |
| Departure Point Same as Event | Yes |
| Departure Airport Code | SAT |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 711 |
| Departure Time Zone | CST |
| Destination Same as Local Flt | -- |
| Destination Airport Code | EGP |
| Destination City | EAGLE PASS |
| Destination State | TX |
| Destination Country | |
| Specific Phase of Flight | Landing |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:34AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 12R |
| Runway Length | 8502 |
| Runway Width | 150 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |