Naples Municipal Airport
Aircraft Accident/Incident Report

Naples, Florida 34104
Thursday, January 22, 2009 19:10 EST

NTSB Narrative Summary Released at Completion of Accident

In the three months prior to the incident there were no reported discrepancies by any flight crew member related to either fuel selector valve. The incident flight was the pilot's fourth flight of the day in the incident airplane. The first three flights were uneventful; however, the pilot noticed that the difference between the left and the right fuel quantities became increasingly larger during the second, third, and fourth flights when the left fuel quantity indicator was indicating a greater amount than the right. During the third flight, the pilot attempted to correct the fuel imbalance by supplying fuel to both engines from the left main fuel tank for a brief period, then returned the right fuel selector to the right tank position. Before takeoff of the incident flight, the pilot noted a 100-pound fuel imbalance; the left fuel quantity was indicating 300 pounds and the right fuel quantity was indicating 200 pounds. While climbing to 6,000 feet, he noticed a slight right-wing-heavy tendency but did not correct it at that time. The flight continued toward the destination airport and the fuel imbalance became greater as the flight progressed. Approximately halfway into the flight, for approximately 15 minutes, the pilot repositioned the left fuel selector to the right tank position; at that time the left fuel quantity gauge indicated 300 pounds and the right fuel quantity gauge indicated between 90 and 100 pounds. After 15 minutes he repositioned the left fuel selector to its respective tank position but was not able to position it into the detent and he failed to detect that the left fuel selector was not in the detent. The flight continued toward the destination airport with both engines being supplied fuel from the right main fuel tank. As the flight approached an area called Marco Island, the pilot became concerned because the left fuel quantity gauge was indicating 300 pounds and the right fuel quantity gauge indicated 50 pounds. He later stated that he thought the imbalance to be an indication issue. The flight continued toward the destination airport and the right engine began surging; the right fuel quantity indicator was indicating zero at that time while the left fuel quantity indicator was indicating approximately 300 pounds. He immediately moved the right fuel selector to the left tank position (crossfeed), which restored engine power; then the left engine began to surge, followed by the right engine. Unable to restore engine power in both engines, the pilot declared an emergency with air traffic control and executed a 180-degree turn towards Naples Municipal Airport. While descending he successfully feathered both propellers and landed uneventfully on runway 14 at the Naples Municipal Airport. Following recovery of the airplane only residual fuel was noted in the fuel lines and both engine compartments, which is consistent with total fuel starvation. An adequate quantity of fuel was noted in the left main fuel tank. Postincident testing revealed the left main fuel selector would not travel into the main tank detent upon selection in the cockpit because of inadequate lubrication of the fuel selector detents. Lubrication of the fuel selector detents was not being performed by the operator due to their misinterpretation of the airplane manufacturer maintenance manual. Additionally, the operator was using an incorrect lubricant on the fuel selector gearbox. Misinterpretation of the maintenance manual also occurred with six other operators who operate the Cessna 402C airplanes. Both engines operated normally after an adequate quantity of fuel was supplied to them.

NTSB Probable Cause Narrative

The pilot's failure to recognize that both engines were being supplied fuel only from the right main fuel tank, resulting in fuel starvation and a subsequent loss of engine power from both engines. Contributing to the incident were the pilot's inability to properly position the left fuel selector valve and the airplane operator's misinterpretation of the manufacturer's service recommendations to lubricate the fuel selector detents.

Event Information

Type of Event Incident
Event Date 1/22/2009
Event Day of the Week Thursday
Time of Event 1910
Event Time Zone Eastern Standard Time
Event City Naples
Event State FLORIDA
Event Country --
Zipcode of the event site 34104
Event Date Year 2009
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 260905N
Event Location Longitude 0814619W
Event Location Airport Naples Municipal Airport
Event Location Nearest Airport ID APF
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 8
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1853 Eastern Standard Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID APF
Elevation of weather observation facility 8
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation EST
Lighting Conditions Night
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 13
Dew Point at event time (in degress fahrenheit) 3
Wind Direction (degrees magnetic) 330
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 3
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.26
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 7
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 27228
NTSB Notification Source Continental Airlines
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Nov 18 2010 1:10PM
User who most recently changed record lema
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2615G
NTSB Number ERA09IA140
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 402C
Aircraft Series Identifier --
Aircraft Serial Number 402C0101
Certified Max Gross Weight 7210
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 1
Cabin Crew Seats --
Passenger Seats 9
Total number of seats on the aircraft 10
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection AAIP
Date of Last Inspection Jan 13 2009 12:00AM
Airframe hours since last inspection 38
Airframe Hours 23631
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name HYANNIS AIR SERVICE INC DBA
Aircraft Owner Street Address 660 BARNSTABLE RD
Aircraft Owner City HYANNIS
Aircraft Owner State MA
Aircraft Owner Country USA
Aircraft Owner Zipcode 02601-1927
Operator is an individual? No
Operator Name HYANNIS AIR SERVICE INC
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country USA
Operator Zip code --
Operator Code HYIA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number HYIA145B
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code EYW
Departure City Key West
Departure State FL
Departure Country USA
Departure Time 1828
Departure Time Zone EST
Destination Same as Local Flt --
Destination Airport Code RSW
Destination City Fort Myers
Destination State FL
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Aug 25 2010 11:29AM
User who most recently changed record broda
Since inspection or accident Time of Accident
Event Location Runway Number and Location 14
Runway Length 5000
Runway Width 75
Sight Seeing flight No
Air Medical Flight No
Medical Flight --