A Pilot’s Siege of Troubles Leads to a Fatal Outcome

One takeaway from this tragedy: Altitude is the best defense.

In September 2018, a Canadian-registry Cessna 340A attempting to land at Port Huron, Michigan (KPHN), crashed a half-mile past the departure end of the runway. The airplane was destroyed, and its 690-hour private pilot, the only person aboard, was killed. The accident occurred in darkness and rain, just before midnight, but in VFR conditions.

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The pilot, on a business trip to Wisconsin, had left Carp Airport at Ottawa, Ontario (CYRP), around 7:30 p.m. after waiting four hours for a truck to arrive and replenish the airport’s fuel supply. En route at 23,000 feet, he encountered thunderstorms and diverted to St. Thomas, Ontario (CYQS), where he waited on the ground for an hour before continuing to KPHN. He remained at 4,000 feet for the short IFR flight and, on nearing KPHN, was cleared for the GPS Runway 22 approach.

When the airplane was at 1,050 feet agl, the pilot reported that he had not been able to turn on the runway lights, which are activated at the nontowered airport by mic clicks on the common traffic advisory frequency. The runway was invisible.

At 650 feet above the airport, the pilot said, “I’m right above the airport on one engine, so I’m gonna make a slow turn…to reshoot the approach.”

The pilot’s last transmission came a few seconds later. “There’s nothing lit up here, sir,” he said. The last radar return from the 340 had it at 450 ft agl and beginning a right turn. Evidently, it stalled out of that turn, descending almost vertically to the ground.

In the morning, airport personnel checked the runway lights. They operated normally.

Teardown of the right engine revealed nothing amiss. The airplane was equipped with an electronic engine-monitoring system, however, and it showed an abrupt loss of fuel pressure at the time of the engine failure. There was nothing apparently wrong with the engine-driven fuel pump, and the auxiliary-pump switch was on. Accident investigators concluded that the pilot had mismanaged the airplane’s somewhat arcane fuel system, and the right engine had quit because of fuel starvation.

The 340 had three fuel tanks for each engine: the 50-gallon wingtip tank, which was the main, a midspan auxiliary tank of 31.5 gallons and a 20-gallon wing locker tank in the aft part of the engine nacelle. The locker tanks did not feed the engines directly; transfer pumps moved their fuel into the main tanks at a rate of about 13 gph.

The standard fuel-management procedure was to use the main tanks for the first 90 minutes after takeoff and in all phases of flight except while cruising at altitude, when the aux tanks could be selected once the fuel levels in the mains were below 180 pounds. The locker-tank transfer pumps were to be switched on after takeoff and run until the locker tanks were dry. Because their flow rate was less than the engines’ consumption, the fuel level in the main tanks would slowly decline. The 180-pound rule was intended to preclude overflowing the main tanks.

Most of the fuel tanks broke open in the crash, but 14 gallons remained in the right locker tank. It should not have been there. The airplane had flown about three hours since full tanks, and the locker tanks ought to have been empty after 90 minutes. The amount of fuel found in the right locker tank was consistent with the duration of the final flight, however, if the transfer pumps had been turned on, as required, shortly after takeoff. Investigators hypothesized that because the wing locker fuel had not been transferred to the mains, the pilot had switched to auxiliary fuel prematurely and then inadvertently run the right aux tank dry. The right engine’s fuel selector valve was found with the main tank selected; the investigators’ theory was that the pilot recognized his error and tried to restart the right engine but failed. Consistent with this scenario was the fact that he had not feathered the propeller or taken any of the other steps needed to secure a dead engine.

The hypothesis that the pilot tried and failed to restart the engine—and became fixated and distracted by the process—is also consistent with his gravest error: He left the gear and flaps down. Like most piston twins, the 340A won’t climb unless cleaned up. The POH makes no bones about the single-engine performance, emphasizing the “immediate action” steps needed to secure an inoperative engine and suggesting they be committed to memory. This airplane enjoyed the advantage of 50 extra horsepower thanks to a RAM conversion, but even that could not overcome gear, flaps and a windmilling propeller.

In addition to failing to clean up the airplane, the pilot allowed its airspeed to bleed away. His groundspeed at the FAF was 100 knots, but at the last radar return, it was 72.

The pilot’s actions and omissions may reflect the state of mind of someone who is arriving at an airport of entry five hours later than he intended to. He is tired; he wants to land. The fact that he delayed reporting the engine failure for more than a minute suggests that he recognized the cause was nothing more than fuel starvation and thought he could remedy it without first climbing back to a safe altitude.

Editor’s note: These articles are based in part upon the NTSB final report for a given accident. The intention is to bring the probable and contributing causes of these accidents to our readers’ attention, so they can learn from them and apply them to their own flying.

The radio settings were lost in the crash, but he had evidently made a mistake selecting the CTAF frequency to activate the runway lights. Now his problem was more urgent; he could not land even if he did get the engine running again. And yet, he still failed to clean up the airplane and start climbing, most likely because he was convinced that the engine would restart at any moment, and he would then turn his attention to other things.

The National Transportation Safety Board’s analysis listed four causes, all pilot errors: improper fuel management, inadequate flight planning, failure to secure the right engine after loss of power, and failure to configure the airplane for a go-around.

I’m not sure what aspect of his flight planning was considered inadequate—unless, by flight planning, they meant in-flight decision-making. To me, the crux of this accident is simply the pilot’s failure to take what seems to be the only sensible action, namely, to get the hell out of there. Less than 1,000 feet above the ground, no airport in sight and one engine windmilling—how much worse can it get? At least he wasn’t on fire. But that’s not the time or the place to attempt a restart. The POH had it right: feather, clean up, maintain climbing speed—it’s 100 kias—and get to a safe altitude. Then diagnose the problem, try to restart or fly to an airport at which landing is assured.

It’s all very clear—in hindsight and my easy chair.

This story appeared in the April 2020 issue of Flying Magazine


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