N51RX

HISTORY OF FLIGHTOn August 27, 2014, about 1903 mountain daylight time, a Cessna 421C airplane, N51RX, impacted terrain during initial climb near Las Cruces International Airport (LRU), Las Cruces, New Mexico. The pilot, two medical crewmembers, and one patient were fatally injured. The airplane was destroyed. The airplane was registered to Elite Medical Air Transport, LLC, El Paso, Texas, and was operated by Amigos Aviation, Inc., Harlingen, Texas, as a 14 Code of Federal Regulations Part 135 air ambulance flight. Day visual meteorological conditions prevailed at the time of the accident at the accident site, and an instrument flight rules flight plan had been filed. The airplane departed LRU destined for Phoenix Sky Harbor International Airport (PHX), Phoenix, Arizona.

The airplane arrived at LRU about 1822 to load the patient for a flight to PHX. According to the line service technician who worked for the fixed-base operator (FBO), both engines were shut down and the pilot was still seated in the cockpit when he asked the technician to add 40 gallons of fuel to the airplane; the pilot did not specify the type of fuel. The line service technician drove a fuel truck to the front of the airplane and then added 20 gallons of fuel to each wing tank. The pilot then helped the line service technician replace both fuel caps. The line service technician then printed the fuel ticket, which the pilot signed.

At 1901:45, shortly after departure, a medical crewmember onboard the airplane called the company medical dispatcher and reported that the flight was returning to LRU because smoke was coming from the right engine. A witness driving on the interstate highway near the airport reported seeing the airplane flying about 200 ft. above ground level (agl) with smoke coming from the right engine. The airplane then began descending and entered a left turn. Another witness driving on the highway reported seeing smoke trailing from the airplane when it passed over him about 100 ft. agl. He saw the descending airplane continue to turn left and then lost sight of it. Several other witnesses reported seeing or hearing the impact and then immediately seeing smoke or flames. PERSONNEL INFORMATIONPilot

The pilot held a Federal Aviation Administration (FAA) airline transport pilot certificate with airplane single-engine land and multiengine land ratings. He also held an FAA flight instructor certificate with airplane single-engine, multiengine, and instrument airplane ratings. The pilot was issued an FAA first-class airman medical certificate with no limitations on October 28, 2013.

The pilot's personal logbooks were not available for examination. Based on FAA records, pilot training documents, and other records from Amigos Aviation, the pilot's flight experience was estimated to be 2,432 total flight hours, of which 1,553 hours were in multiengine airplanes and about 1,379 hours were in Cessna 421 airplanes.

Line Service Technician

The line service technician had been employed by the FBO since April 7, 2014. He stated that he had no previous work experience in aviation, he did not hold an FAA airman certificate of any kind, and he was not a pilot or an aircraft mechanic. FBO records showed he had completed its on-job-training program and been issued an American Petroleum Institute Class C training certificate. At the time that he refueled the airplane, he was the only FBO employee on duty. AIRCRAFT INFORMATIONThe low-wing, retractable-landing-gear, pressurized, multiengine airplane, serial number (S/N) 421C0871, was manufactured in 1981. It was powered by two 375-horsepower Continental Motors GTSIO-520-L turbo-charged engines. Engine S/N 292408 was installed on the left side, and engine S/N 292022 was installed on the right side. Each engine drove a three-bladed, variable pitch, full-feathering McCauley propeller.

A review of the aircraft maintenance records showed that an annual inspection had been completed on March 5, 2014, at an aircraft total time of 8,181.4 hours and an hour meter reading of 869.6 hours. A maintenance logbook entry dated August 24, 2014, showed the hour meter reading was 904.3 hours. FAA records showed that the airplane had been registered to Elite Medical Air Transport, LLC since April 15, 2010.

The airplane was equipped with Micro Aerodynamics vortex generators, which were installed in accordance with FAA-approved Supplemental Type Certificate SA5193NM.

Preaccident photographs of the airplane showed labels near the fuel filler ports that had black letters on a white background and stated, in part, "AVGAS ONLY." A postaccident review of refueling records and statements from the line service technician revealed that the airplane had been misfueled with 40 gallons of Jet A fuel instead of the required 100LL aviation gasoline.

The airplane was not equipped with, and was not required to be equipped with, either a cockpit voice recorder or a flight data recorder. METEOROLOGICAL INFORMATIONAt 1855, the automated weather observing system at LRU, located about 4 miles northeast of the accident location, reported wind from 040° at 5 knots, visibility of 10 miles, broken clouds at 6,500 ft., temperature 23°C, dew point 16°C , and an altimeter setting of 30.16 inches of m ercury. AIRPORT INFORMATIONThe low-wing, retractable-landing-gear, pressurized, multiengine airplane, serial number (S/N) 421C0871, was manufactured in 1981. It was powered by two 375-horsepower Continental Motors GTSIO-520-L turbo-charged engines. Engine S/N 292408 was installed on the left side, and engine S/N 292022 was installed on the right side. Each engine drove a three-bladed, variable pitch, full-feathering McCauley propeller.

A review of the aircraft maintenance records showed that an annual inspection had been completed on March 5, 2014, at an aircraft total time of 8,181.4 hours and an hour meter reading of 869.6 hours. A maintenance logbook entry dated August 24, 2014, showed the hour meter reading was 904.3 hours. FAA records showed that the airplane had been registered to Elite Medical Air Transport, LLC since April 15, 2010.

The airplane was equipped with Micro Aerodynamics vortex generators, which were installed in accordance with FAA-approved Supplemental Type Certificate SA5193NM.

Preaccident photographs of the airplane showed labels near the fuel filler ports that had black letters on a white background and stated, in part, "AVGAS ONLY." A postaccident review of refueling records and statements from the line service technician revealed that the airplane had been misfueled with 40 gallons of Jet A fuel instead of the required 100LL aviation gasoline.

The airplane was not equipped with, and was not required to be equipped with, either a cockpit voice recorder or a flight data recorder. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted desert grasslands operated by the United States Bureau of Land Management at a terrain elevation of about 4,420 ft. mean sea level. On-scent evidence showed that the airplane was generally eastbound and upright when it impacted terrain, which resulted in the separation of the left propeller blades and right aileron. The airplane came to rest inverted about 78 ft. east of the initial impact point on a wreckage debris path of about 93°, and an immediate postimpact fire consumed most of the airplane. The nose of the inverted fuselage was oriented to about 160°. All major components of the airplane were observed and accounted for at the scene. Investigators who arrived at the scene on the day following the accident reported clearly detecting the smell of jet fuel.

Both engines, most of the left wing, the inboard portion of the right wing, and all of the tail surfaces remained attached to the fuselage. The right aileron was completely separated from the airplane and came to rest about 55 ft. to the southeast of the main wreckage.

Control cable continuity was confirmed from the cockpit to the respective flight control surfaces except for cable separations consistent with either cable cuts by first responders or tensile overload. Thermal and impact damage prevented an assessment of any of the cockpit instruments.

The left aileron trim actuator extension was measured, and it was about 1/4 inch, which corresponded to a setting of about 21° trim tab trailing edge down (airplane nose up). The left and right elevators remained attached to their respective horizontal attachment points. The right elevator trim tab remained attached to the right elevator. The right elevator trim actuator extension was measured, and it was 11/16 inch, which corresponded to a setting of about 21° trim tab trailing edge down.

The rudder remained attached to the vertical stabilizer attachment points, and the rudder trim tab remained attached to the rudder. The rudder trim actuator extension was measured, and it was 2 1/4 inches, which corresponded to a neutral rudder trim position. Measurements of the flap mechanism corresponded to a flap extension of about 9° flaps down. All three landing gear assemblies remained attached and appeared to be in the retracted position.

The left propeller hub remained attached to the left engine crankshaft propeller flange; however, all three propeller blades were completely separated from the propeller hub. The propeller blade marked as "1" was found 502 ft. southwest of the main wreckage; the propeller blade marked as "2" was found 285 ft. east of the main wreckage; and the propeller blade marked as "3" was found 55 ft. southeast of the main wreckage. None of the propeller blades exhibited significant twisting, leading edge gouges, or chordwise scratches; however, the outer 12 inches of the No. 2 blade was bent toward the camber side, and the outer 8 inches of the No. 3 blade was bent toward the camber side.

The right propeller assembly remained attached to the right engine crankshaft propeller flange, and all three blades remained attached to the propeller hub. The...