In the past, the NTSB has, from time to time, come under criticism for being too quick to blame accidents on pilot error. Every so often, though, investigators come up with a solid case for placing the probable cause squarely and firmly in the lap of the pilot.
One such accident involved a Canadian-registration Cessna 340A that was on an instrument approach at night, in instrument conditions, to St. Clair County International Airport (KPHN) in Port Huron, Michigan, on Sept. 5, 2018. The pilot, who was the only person on board, was killed. The airplane, owned by a corporation, was being operated as a Part 91 business flight. It had taken off from St. Thomas Municipal Airport in St. Thomas, Ontario, Canada.
According to information gathered by investigators, the airplane was based at Carp Airport in Ottawa in Ontario, Canada. The pilot originally had intended to fly direct from Carp to Port Huron, but his departure was delayed by four hours when he had to wait for fuel at Carp. The airport was out of fuel, and the pilot waited until a truck arrived with a fresh supply. Then, while en route, he ran into bad weather and had to divert to St. Thomas. The flight lasted about two hours and 23 minutes. There was no record of the pilot having bought fuel at St. Thomas.
The pilot planned to clear U.S. Customs at Port Huron, then fly to a destination in Wisconsin where he would be attending a trade show for his wood processing business. An NTSB investigator suggested the intended destination might have been Oshkosh.
The pilot was 51 years old and held a Canadian private pilot license with single-engine, multi-engine and instrument ratings. His logbook showed about 690 hours total time, with 51 hours in the Cessna 340A.
The twin-engine airplane had been reconfigured with five seats instead of the six with which it had been manufactured in 1981. It was equipped with two Continental TSIO-520-NB9A engines that had been modified to each produce 335 horsepower. It had undergone an annual inspection that was signed off about four months earlier, on May 16, 2018, at an aircraft total time of about 4,038 hours.
The airplane’s fuel system used six tanks, three on each side. The 50-gallon main tanks were mounted on each wingtip. There were 31.5-gallon auxiliary tanks in the outboard wings and two 20-gallon wing locker tanks. The fuel selectors, one for each engine, were located between the pilot seats.
The aircraft’s Pilot Operating Handbook (POH) had specific instructions regarding when to use the various tanks and the auxiliary fuel pumps for the engines. It also had specific procedures to be followed should there be an engine failure during flight that included checking the fuel flows, checking fuel quantities and being sure the proper tanks had been selected. Some items were designated as “immediate action” items that should be committed to memory.
The 340A took off from St. Thomas at about 11:04 p.m. and climbed to 4,000 feet. The pilot was cleared direct to the initial approach fix, WYDUK, for the RNAV (GPS) approach to Runway 22 at Port Huron. At about 11:35, the Cessna was handed off to the Lansing Sector controller at Cleveland Center and checked in at 4,000 feet. The controller asked him to confirm that he was going direct to WYDUK, which the pilot did.
“Report passing WYDUK and just confirm you have the weather for Port Huron and contact flight service to get the NOTAMS,” the controller radioed. The pilot asked the controller to “say again.” The controller repeated the transmission, and the pilot advised he had the weather for the airport and would contact flight service to get the NOTAMS.
The pilot asked for the flight service frequency, and the controller gave him 122.2, which the pilot confirmed.
At 11:37:29, the controller advised the pilot to report passing WYDUK and advised that radar contact had been lost. The airplane apparently had descended below the floor of radar coverage in that area. About 20 seconds later, the pilot radioed that “there is no response to that sector,” an apparent reference to flight service.
The controller asked the pilot if he had picked up the NOTAMS before departure. “There was nothing noticeable,” the pilot replied. A few seconds later, the controller radioed, “I show there’s a [sic] obstructed tower light that, uh, NOTAMED, and there’s—that’s the only thing that I show that’s NOTAMED at Port Huron.” The pilot replied, “Okay, copy that.”
At 11:39:04, the controller said, “And it’s, uh, three point one nautical miles northeast of Port Huron, and the light is out of service on that tower. That’s what it shows, and it’s 872 feet.” The pilot’s response was unintelligible.
At 11:42:18, the controller radioed to find out if the airplane had crossed WYDUK, and the pilot radioed that he had. The controller then advised the pilot to cross the final approach fix ZORIX at or above 2,200 feet, that he was cleared for the approach and to cancel IFR in the air with him on frequency 126.52 or on the ground with flight service. The controller cleared the pilot to change to the airport Common Traffic Advisory Frequency (CTAF).
The NTSB reported that even though the airplane had been previously lost from radar, radar track data indicated that the flight was at 4,000 feet and at a ground speed of 127 knots when the controller released it to the CTAF.
Investigators examined data from the airplane’s engine monitor and noted that there was a rapid decrease in fuel flow to the right engine at 11:43:23. Coincident with that were decreases in exhaust gas temperature (EGT) and rpm. The airplane was about 1.3 nautical miles from the final approach fix at the time. The fuel flow, EGT and rpm went back up for a few seconds, then down.
The airplane crossed ZORIX at 11:44:01. It was at 3,500 feet with a ground speed of 118 knots. Right engine data showed it again briefly gained some power, going up to 600 rpm.
At 11:44:33, the pilot radioed, “Uh, just lost my right engine.” The controller responded, “Uh, roger. You going to be able to make the landing at Port Huron?” The pilot replied, “I’m going to work on it.”
The controller alerted his supervisor, “I had a small IFR guy into Port Huron. Just reported lost his right engine. He said he’s going to try to still land there but, uh, 3,400 feet is the last time I saw him.” The supervisor thanked him for the heads up.
At 11:46:41, the pilot radioed, “I see no lights at the runway, uh, and I tried to turn them on. They don’t turn on.” The controller replied, “They’re not NOTAMED out, and I don’t have control over them. I’m not sure—do you see the airport?” The pilot replied that he didn’t see it. “I’m right above the airport on, uh, one engine, so I’m gonna make a slow turn [unintelligible] to reshoot that approach.”
The controller asked, “Do you see the airport now that you’re right above it?” “There’s nothing lit up here, sir,” the pilot said. The airplane was down to 1,200 feet with a ground speed of 84 knots.
At 11:48:32, the controller advised, “There’s a small private strip that is south of your pos…south of Port Huron by about, oh, seven miles or so. Uh, I don’t know if you can get the lights on on that. I don’t have a frequency. I can work on finding it for you if you still don’t see the airport.” There was no response, and a minute later, the controller tried to raise the pilot, but again there was no response. The last radar hit indicated that the airplane was at 1,100 feet and had turned right to head toward the west and was making about 72 knots across the ground.
After a few minutes, the controller asked the crew of a United Air Lines flight to try to raise the Cessna pilot, but they had no luck.
The Cessna had crashed in a grass area amid baseball fields about ⅔ nautical miles from the departure end of Runway 22. There was localized fire damage to parts of the airplane. There were signs of fuel having been spilled on the grass around the wreckage, and 14 gallons of fuel were found in the right wing locker tank. Both the landing gear and flaps showed evidence of having been extended prior to the crash. Investigators found no evidence that the engines or other components or systems had malfunctions or failures that would have precluded normal operation. The right prop was found not to have been feathered, something you’d expect a pilot to do when handling an engine failure in a twin.
The NTSB found that the RNAV (GPS) RWY 22 approach plate identified the pilot-controlled lighting as being on frequency 123.05, the airport’s CTAF frequency. Both the precision approach path indicator and runway lights were jointly controlled on that frequency. Three clicks would turn on the PAPI and set the runway lights on low, five clicks would raise the intensity to medium, and seven clicks would put the lights at high. They were timed to stay on for 15 minutes. The lights were found to be fully operational when checked by airport personnel on the morning after the accident.
The weather observation at Port Huron about 12 minutes before the crash included calm wind, visibility 10 miles or more, scattered clouds at 5,000 feet and 7,000 feet with a broken ceiling at 12,000 feet. There was moderate rain. The temperature was 21 degrees C, and the dew point was 20 degrees C.
Significantly, the approach plate for the approach stated that night landings on Runways 22, 10 and 28 at Port Huron were not authorized. Runway 4 was the only one at the airport classified as being usable for a night approach. It was equipped with an ILS. Investigators were told by airport management that the reason for not allowing night landings on the three runways was obstructions caused by trees.
The NTSB found that the probable cause of the accident was the pilot’s improper fuel management, which resulted in a total loss of right engine power due to fuel starvation; the pilot’s inadequate flight planning; the pilot’s failure to secure the right engine following the loss of power; and his failure to properly configure the airplane for the go-around, which resulted in the airplane’s failure to climb, exceeding the critical angle of attack and an aerodynamic stall.
The evidence certainly supports the NTSB’s conclusions that this was an accident involving pilot error. Unfortunately, it leaves it up to us to figure out why those errors occurred.
Why didn’t the pilot see the note on the approach plate about night approaches? Dark cockpit? Distraction? Failure to brief himself on the airport before even getting into the plane?
Why didn’t the pilot properly secure the stopped engine? Forgetfulness? Ignorance about the procedure?
Why did the pilot mismanage the fuel? Fuel system too complex for him? Not enough training?
An important part of learning lessons from pilot error accidents is learning why the pilots made the errors so we can try to avoid going down the same path.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.