West Creek, NJ, USA
N5382S
CESSNA 337A
The multi-engine airplane was one of several owned and operated by the pilot, who flew many of the missions, and conducted most of the maintenance. The three passengers were employees of an environmental services company that was contracted to conduct aerial surveys of marine mammals. Each month, the pilot re-positioned the airplane from his base in Massachusetts to New Jersey to conduct the survey flights. The previous month, the survey personnel documented concerns with the pilot's performance, and the condition of the airplane. For the accident flight series, the pilot arrived 1 1/2 days late, and one surveyor documented the passengers' concerns about the pilot's performance and fatigue. About 90 minutes into the accident flight, the pilot informed the passengers that he "was having some fuel problems," terminated the survey, and diverted for a precautionary landing. One passenger saw the front propeller stop and begin rotation more than once. The airplane impacted trees and terrain approximately 400 feet to the side of the runway threshold. Several witnesses saw the airplane descend, heard it crash, and notified authorities, but the unsuccessful search efforts were terminated about 2 hours after the accident. A surviving passenger used his mobile phone to call for assistance, and the wreckage was located about 2 hours after that, which was about 4 hours after the accident. The pilot and a passenger were killed, and two passengers survived. Autopsy results indicated that the pilot incurred a transected aorta, which is a non-survivable injury. The fatally-injured passenger incurred a cervical fracture and a transverse basilar skull fracture. Though such injuries are commonly fatal, it is possible that appropriate and more immediate medical treatment would have increased the chances of the passenger’s survival. Post accident examination. Post accident examination revealed that the battery for the emergency locator transmitter bore a "replace by" date that was four years prior to the accident. Neither propeller exhibited evidence of rotation during impact. While all fuel tanks were intact, the main tanks were empty, one auxiliary tank contained 11 gallons, and the other one contained 2 gallons. Records indicated that the airplane was not refueled between the previous flight and the accident flight. The manufacturer's Owner's Manual indicated that the engines can only be primed from the main tanks, and the "Engine-Out During Flight" checklist specified that the fuel selector valve should be set to the main tank for an engine restart attempt. Both engines were successfully test-run after the accident.
HISTORY OF FLIGHT On May 17, 2008, about 1245 eastern daylight time (EDT), a Cessna 337A, N5382S, was substantially damaged when it impacted trees and terrain while attempting to divert to Eagles Nest Airport (31E), West Creek, New Jersey. The certificated commercial pilot and one passenger were fatally injured, and the other two passengers were seriously injured. The pilot was the owner of Ambroult Aviation, which operated the marine mammal survey flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. A Texas-based environmental services company was contracted to provide marine mammal survey information for a study by the New Jersey Department of Environmental Protection, and the environmental services company contracted with the operator to conduct the survey flights. The three passengers were employees of the environmental services company. The pilot and airplane were based at Chatham Municipal Airport (CQX), Chatham, Massachusetts, but temporarily relocated to Millville Airport (MIV), Millville, New Jersey each month for the survey flights. According to an environmental services company representative, the survey flights with the accident pilot and airplane began in January 2008, were conducted on a monthly basis, and were scheduled for completion by July, 2008. According to the environmental services company documentation, the survey area extended approximately 80 miles north-south along the New Jersey shoreline, and extended approximately 20 miles east over the Atlantic Ocean. Each monthly survey consisted of flying 30 numbered course lines, called transects, to cover the entire survey area. Each transect was to be flown at 750 feet above mean sea level (MSL). According to the environmental services company personnel, the pilot and airplane were scheduled to arrive at MIV on May 14, in order to begin the survey at 0700 on May 15. At some point on May 14, the pilot advised the company that he would not arrive at MIV until May 15. According to personnel and records from the Millville Jet Center at MIV, the airplane arrived about noon on May 15, and the pilot requested that the "mains be topped off." The airplane was serviced with 55 gallons of 100LL avgas about 1210. No records of any subsequent fuel servicing could be located. The passengers had planned to complete the full survey grid on May 15, but the pilot arrived too late to accommodate their plan. The pilot provided different explanations for his delay to the passengers and to a mechanic at CQX. According to information obtained from passenger interviews, passenger survey notes, and a handheld global positioning system (GPS) unit recovered from the wreckage, the May 15 survey flight began when it departed from MIV at 1244. Due to the lateness of the day and the passengers’ concern about the pilot being tired, only half the survey grid was completed. The airplane returned to MIV, and the engines were shut down at 1721. The surveyors intended to complete the grid the next day, May 16, but the weather conditions were unacceptable for the survey, and the flight was rescheduled for Saturday, May 17. The weather conditions on May 17 were improved, but the passengers were concerned about the wind, since wind affected their ability to conduct the survey. After some delay, they decided to try, and the airplane departed on the accident flight from MIV about 1104. The day's survey began with transect 14, which was approximately 60 miles from MIV. Transect 14 was started at 1147, and was finished at 1159. Transect 15 was started at 1201, and was finished at 1226. Transect 16 was started at 1228. All four individuals on board could hear and talk to one another, and the passengers could hear all the pilot’s radio calls. According to the passenger in the right rear seat, at some point "after finishing the third survey line," the pilot remarked that he would have to "break off" the survey because the airplane "was having some fuel problems," and that he needed to "go back." The passenger also saw the pilot repeatedly manipulating the fuel selector valve handles. The passenger stated that he observed the front propeller cease and resume rotation several times. The passenger stated that according to the pilot, they would divert for landing to the "closest airstrip." One passenger asked how far it was to the nearest airstrip, and the front seat passenger replied "about 10 minutes." No-one specifically mentioned any particular airport. During the diversion, the right rear passenger did not hear the pilot communicate with anyone on the radio about the problem or his intentions. The passenger had the impression that the airplane was in a continuous descent, and stated that the engines continued to make unusual noises, as if they were running roughly. At some point, the pilot mentioned to the passengers that there was "another [airport] close," and he requested their assistance in visually locating the airport. Shortly thereafter the left rear passenger visually located 31E, and he informed the pilot that it was off to the left at their "nine-o’clock position." The right rear passenger then visually located the airport, but the airplane "started falling," and impacted trees. The right rear passenger stated that the landing gear remained extended for the duration of the flight on May 15, and also on the accident flight. The GPS-derived flight path showed that at 1239, the end of transect 16, the airplane turned south along the shoreline and then climbed to a GPS altitude of approximately 1,000 feet. The airplane continued a climb, and about 1241, turned inland and to the north. About 1244, at a GPS altitude of approximately 1,200 feet, the airplane began tracking over New Jersey State Route 72. One minute later, the airplane turned to the southwest, towards 31E, and about 1247 it crossed over the runway at a GPS altitude of approximately 250 feet. Three witnesses, who lived in two separate houses approximately 1/2 mile east of the approach end of 31E runway 32, heard and saw the accident airplane heading for the airport. All three witnesses stated that they were familiar with the sounds and traffic patterns of airplanes using the airport, and that their attention was drawn to the airplane because of its low altitude and unusual sounds. All three stated that the airplane was descending, and that the engine(s) stopped and restarted at least two times. All three heard the sounds of impact. One of the witnesses searched the airport herself for about 10 minutes, but then called 911 about 1302. Personnel from the New Jersey State Police (NJSP) responded, and initiated a search of the local area. According to NJSP records and statements, they did not locate the airplane, and there were no other reports of a missing aircraft, so they abandoned their search about two hours after the initial notification. According to the Texas-based project manager of the Marine Sciences division of the environmental services company, he received a telephone call from the right rear passenger informing him that the airplane had crashed. The passenger told the project manager that he was still in the airplane and that he was injured. The passenger did not know where the accident site was, but he thought that they had just completed transect "12 or 13." Telephone records indicated that this call was made at 1401 central daylight time, which was 1501 EDT, or approximately 2 hours after the accident. The call lasted 4 minutes. The project manager then began attempting to notify various emergency services to inform them of the approximate location of the wreckage, based on the survey transect coordinates. At 1517, the passenger called the project manager again, and the call lasted 2 minutes. Between 1529 and 1616, the project manager attempted to call the passenger seven times, and the passenger attempted to call the project manager once, but no calls were answered. United States Air Force Rescue Coordination Center (RCC) records indicated that they were first notified of the accident at 1542, via a series of telephone calls that were initiated by the environmental services company project manager. The RCC telephoned the passenger, and instructed him to call 911. At 1546 the RCC contacted telephone service providers and requested a trace on the passenger's call, in order to determine which cell phone tower(s) were being used for the call, and thereby obtain a geographic fix on the accident location. According to NJSP dispatch records, the passenger was connected to the NJSP by telephone at 1604. At 1615, a telephone company provided the geographic coordinates of the cell phone tower closest to the accident location, and that, plus correlation of siren and helicopter sounds heard by the passenger with known NJSP activities, enabled the NJSP to narrow the search area. At 1656, a helicopter located the wreckage. The two survivors, both of whom were seated on the right side of the airplane, were extricated and airlifted separately to Atlantic City for medical treatment. PERSONNEL INFORMATION The pilot held a private pilot certificate with airplane single engine land rating, a commercial pilot certificate with an instrument airplane rating and a rating for airplane multiengine land that was limited to aircraft with centerline thrust. He also held a mechanic certificate with airframe and powerplant ratings, and an inspection authorization (IA). The pilot's logbooks were not located. According to documentation that the pilot provided to his insurance company in November 2007, he reported 3,775 total hours of flight experience, 2,810 hours of multiengine flight experience, and 285 hours in the accident airplane make and model. FAA records indicated that the pilot’s most recent second-class medical certificate was issued in December 2007. According to documentation provided by a certificated flight instructor, the pilot's most recent flight review was successfully conducted on February 24, 2008. None of the three passengers held any pilot certificates. AIRCRAFT INFORMATION The accident airplane was manufactured in 1966, and was first registered to the pilot in March 1998. It was a six place, high wing airplane of all metal construction, with retractable, tricycle configuration landing gear. It was equipped with two Teledyne Continental Motors (TCM) IO-360 piston engines, one each at the front and rear of the fuselage. Each engine was equipped with a full-feathering, two-bladed McCauley propeller. The fuel system consisted of three metal tanks in each wing. Two interconnected tanks in the outboard section of each wing comprised each main tank. Each main tank had a total capacity of 46.5 gallons, of which 46 were usable. One auxiliary tank was located in the inboard section of each wing, each with a total capacity of 19 gallons, 18 usable. Total airplane fuel capacity was 131 gallons, of which 128 were usable. Either main tank could provide fuel to either engine, but the left auxiliary tank could only provide fuel to the front engine, and the right auxiliary tank could only provide fuel to the rear engine. METEOROLOGICAL INFORMATION The 1254 weather observation at an airport located approximately 20 miles south of the accident airport, reported winds from 250 degrees at 11 knots with gusts to 16 knots, clear skies, 10 miles visibility, temperature 21 degrees C, dew point 7 degrees C, and an altimeter setting of 29.61 inches of mercury. WRECKAGE AND IMPACT INFORMATION The majority of the wreckage was tightly contained in a wooded area approximately 400 feet south of the approach end of runway 32. The main wreckage consisted of the entire airplane, with the exception of the outboard third of the left wing. The fuselage was lying on its left side, and oriented on a magnetic heading of approximately 140 degrees. The right wing was standing on its leading edge, and partially attached to the fuselage. The inboard two-thirds of the left wing was right side up, and partially attached to the fuselage. The outboard third of the left wing was located approximately 120 feet north of the main wreckage. The front engine was completely separated from the airplane, and was right side up. The front engine exhibited significant impact damage on its lower side. The propeller remained fully attached to the hub, and the hub was fully attached to the engine. One propeller blade was straight, and the other blade exhibited significant bending. Neither of the blades displayed any chordwise scratching. The forward spinner had a 6 inch by 10 inch dent, and this dent contained linear material transfer marks which were oriented parallel to the longitudinal axis of the engine. The engine was able to be hand-rotated through approximately 270 degrees. There was fuel in the fuel pump, the fuel pump drive was intact, and the pump rotated freely. The fuel strainer was full of fuel. The upper spark plugs exhibited normal wear characteristics and coloration. The rear engine was inverted, displaced forward and to the left of its design location, but partially attached to the fuselage. The propeller remained fully attached to the hub, and the hub was fully attached to the engine. One propeller blade was straight, and the other blade exhibited significant bending. Neither of the blades displayed any chordwise scratching. The aft spinner was undamaged. The engine hand-rotated freely, and valve train continuity and thumb compressions on all cylinders were confirmed. Functionality and continuity of the ignition system for the upper spark plugs was confirmed. There was a trace amount of fuel in the fuel pump, the fuel pump drive was intact, and the pump rotated freely. The fuel strainer was devoid of fuel, and there were no contaminants in the strainer. The upper spark plugs exhibited normal wear characteristics and coloration. All six fuel tanks were found intact and unbreached, with their caps properly installed. A total of approximately 13 gallons of fuel were recovered from the tanks. The main tanks contained either trace amounts, or were completely devoid, of fuel. The right auxiliary tank contained approximately 11 gallons, and the left auxiliary tank contained approximately 2 gallons. The recovered fuel was clear and bright, with no visible contaminants. Tests with water-detection paste were negative, which indicated that no water was present in the fuel. The two fuel selector valve handles, one for each engine, were located in the cockpit ceiling along the airplane centerline. Each valve handle was connected by a push-pull cable to a fuel valve in one of the wing roots. The fuel selector valve handle for the front engine was found in the "Left Aux" position, and the corresponding fuel selector valve was found set to the port from the left auxiliary tank. The fuel selector valve handle for the rear engine was found in the "Right Main" position, and the corresponding fuel selector valve was found set to an unused port, which was the "off" position. The fuel gauges on the instrument panel were found with the following approximate indications: Left Main, off scale low; Left Aux, 0 gallons; Right Aux, 0 gallons; Right Main, 20 gallons. All master, generator, and fuel pump switches were found in the OFF position. The landing gear handle and the landing gear were found in their respective "gear extended" positions. The flap handle was at the flaps one-third extended position, and flap actuator extension was measured to be 1.8 inches, which corresponded to flaps one-third extended. The elevator trim tab actuator extension was measured as 2.2 inches, which equated to a deflection greater than the 15 degree trailing edge down tab travel limit. The airspeed indicator indicated approximately 85 miles per hour, and the Kollsman window in the altimeter was set to 29.66 inches of mercury. The vertical speed indicator indicated a descent of 825 feet per minute. The artificial horizon indicated approximately level pitch and roll attitudes, and the directional gyro registered approximately 085 degrees. The first two digits on the transponder were missing, and the last two were "70." The emergen
The pilot's departure with insufficient fuel for the planned flight, and his improper in-flight fuel management, which resulted in a total loss of power in both engines due to fuel starvation. Contributing to the accident was the pilot's fatigue, which was precipitated by his work activities during the days just prior to the accident flight.
Source: NTSB Aviation Accident Database
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