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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

January 16, 1989 · Britten-Norman BN-2A · N457SA

Carolina, PR

Overview

Report Status
Probable Cause
Event Type
Accident
Date
January 16, 1989
Injury Outcomes
No injuries (6 uninjured)
Location
Carolina, PR
Aircraft
Britten-Norman BN-2A
Tail Number
N457SA
Injuries
None
Aircraft Damage
Substantial
NTSB Number
MIA89FA065

The pilot ordered 42 gallons of fuel to be added to the aircraft which would bring the total fuel load to 60 gallons. The lineman added 4.2 gallons bringing the total fuel load to 22.2 gallons. The pilot did not verify the fuel load prior to departure. The aircraft was flown from San Juan to Vieques in which 12 gallons were burned. No fuel was added and the pilot again did not verify his fuel load. The flight departed Vieques en route back to San Juan with 10.2 gallons of fuel. On descent into San Juan both engines failed and a forced landing was made in a sugar cane field. After rolling about 100 yards the left landing gear collapsed. Post crash examination of the aircraft revealed it contained 36 ounces of fuel with no evidence of leakage. The engines were operated to full power with no evidence of mechanical failure or malfunction after the accident. The lineman had been hired as a part-time employee on 1/2/89. He stated he was working only his fifth day and that he had no formal refueling training.

NTSB Probable Cause

FUEL EXHAUSTION AND THE FAILURE OF THE PILOT TO INSURE THAT THE PROPER FUEL LOAD WAS PLACED ON THE AIRCRAFT FOR THE FLIGHT. CONTRIBUTING FACTORS INCLUDED THE IMPROPER REFUELING OF THE AIRCRAFT, IMPROPER INITIAL TRAINING OF THE REFUELER AND THE CROP, WHICH CAUSED SUBSTANTIAL DAMAGE TO THE AIRCRAFT.

Full Narrative

THE PLT ORDERED 42 GALLONS OF FUEL TO BE ADDED TO THE ACFT WHICH WOULD BRING THE TOTAL FUEL LOAD TO 60 GALLONS. THE LINEMAN ADDED 4.2 GALLONS BRINGING THE TOTAL FUEL LOAD TO 22.2 GALLONS. THE PLT DID NOT VERIFY THE FUEL LOAD PRIOR TO DEPARTURE. THE ACFT WAS FLOWN FROM SAN JUAN TO VIEQUES IN WHICH 12 GALLONS WERE BURNED. NO FUEL WAS ADDED AND THE PLT AGAIN DID NOT VERIFY HIS FUEL LOAD. THE FLT DEPARTED VIEQUES EN ROUTE BACK TO SAN JUAN WITH 10.2 GALLONS OF FUEL. ON DESCENT INTO SAN JUAN BOTH ENGINES FAILED AND A FORCED LANDING WAS MADE IN A SUGAR CANE FIELD. AFTER ROLLING ABOUT 100 YDS THE LEFT LDG GR COLLAPSED. POST CRASH EXAMINATION OF THE ACFT REVEALED IT CONTAINED 36 OUNCES OF FUEL WITH NO EVIDENCE OF LEAKAGE. THE ENGINES WERE OPERATED TO FULL POWER WITH NO EVIDENCE OF MECHANICAL FAILURE OR MALFUNCTION AFTER THE ACCIDENT. THE LINEMAN HAD BEEN HIRED AS A PART-TIME EMPLOYEE ON 1/2/89. HE STATED HE WAS WORKING ONLY HIS FIFTH DAY AND THAT HE HAD NO FORMAL REFUELING TRNG.

Flight

Event TypeAccident
Event Time18:14 AST
Nearest Airport0nm N
Runway0
Runway Length0
Runway Width0
Flight Plan FiledVFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBritten-Norman BN-2A
Tail NumberN457SA
Aircraft CategoryAir
DamageSubstantial
Operating RulePart 135
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · O-540-E4C5 · Reciprocating · 260
Seats10

People & Injuries

Injury SummaryNo injuries (6 uninjured)
Fatal0
Serious0
Minor0
Uninjured6
Total6
Crew 1Age 35 · First Class

Conditions

ConditionsVMC
LightDusk
Wind120° @ 5 kt
Visibility12 sm
CeilingBroken clouds 9000 ft
Temperature / Dew Point70 F
Altimeter30.00 inHg
Observation Time21:53
Weather SourceWFAC

Appendix: Source Data