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Sun, Aug 20, 2023

NTSB Final Report: Cessna 421

The Fixed-Base Operator’s Incorrect Fueling Of The Airplane, Which Resulted In A Total Loss Of Power In Both Engines

Location: Houston, Texas Accident Number: CEN22LA190
Date & Time: May 6, 2022, 14:18 Local Registration: XB-FQS
Aircraft: Cessna 421 Aircraft Damage: Substantial
Defining Event: Fuel related Injuries: 4 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Analysis: The pilot reported that, before the flight, the airplane was fueled with 140 gallons of Jet A fuel. Shortly after takeoff, both engines lost total power. Because the airplane had insufficient altitude to return to the airport, the pilot executed a forced landing to a field and the left wing sustained substantial damage. A postcrash fire ensued. The investigation determined that the airplane was inadvertently fueled with Jet A fuel rather than AVGAS, which was required for the airplane’s reciprocating engines. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports; however, postaccident examination of the airplane found that a decal specifying AVGAS was present at the right-wing fuel port. The investigation could not determine whether the same or a similar decal was present at the left-wing fuel port because the left wing was partially consumed during the postimpact fire.)

Details: On May 6, 2022, at 1418 central daylight time, a Cessna 421 airplane, Mexican registration XBFQS, was substantially damaged when it was involved in an accident near Houston, Texas. The pilot and three passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot reported that, upon arriving at the airport’s fixed-base operator (FBO) facility, his son requested that the airplane be fueled with 70 gallons in each wing tank. They observed the airplane being fueled; several minutes later, the airplane was towed to their location at the FBO building. The pilot stated that the preflight inspection and taxi for takeoff were completed with no issues found. About halfway through the takeoff roll, the pilot thought that the airplane was “feeling weird” but was unable to stop on the remaining runway. The pilot continued with the takeoff; shortly afterward, the engines began losing power and the airplane had insufficient altitude to return to the airport. The pilot decided to execute a forced landing to a field ahead of the airplane’s flightpath. During the forced landing, the landing gear collapsed and the airplane impacted a perimeter fence. The left wing separated outboard of the engine nacelle and the airplane came to rest in a residential backyard. A postimpact fire consumed the outboard portion of the left wing.

A representative of the FBO stated the pilot’s son placed the order for fuel with a front counter customer service representative. The order was noted as “70 neg each” and confirmed with the pilot’s son. The order relayed to line service was for “70 gallons each wing – negative,” indicating that a fuel additive (Prist) should not be added. The type of fuel was not discussed. The airplane was subsequently fueled with 140 total gallons of Jet A fuel without the Prist additive. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports and that, for that reason, he confirmed the order with the front desk before adding Jet A fuel to the airplane.

The airplane was powered by two reciprocating engines requiring 100/100 low-lead minimum-grade aviation fuel (AVGAS). A postaccident examination by Federal Aviation Administration inspectors found that the right-wing fuel port had decals noting “100/130 Aviation Grade Min” and “AVGAS ONLY.” The decal text was faded but was clearly visible. The investigation could not determine if there were any left-wing fuel port decals because of the fire damage to the left wing. In addition, the truck used to fuel the airplane had a placard indicating “Jet A,” and an elongated fuel nozzle was installed, corresponding with Jet A fueling operations.

After the accident, the FBO implemented additional communication requirements and awareness training related to aircraft fueling to prevent an incorrect fueling event from occurring. 

Probable Cause and Findings: The National Transportation Safety Board determines the probable cause(s) of this accident to be -- The fixed-base operator’s incorrect fueling of the airplane, which resulted in a total loss of power in both engines.

FMI: www.ntsb.gov 

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