Friday, June 14, 2019

Cessna C550 Citation, N744AT: Accident occurred May 09, 2019 in Savannah, Chatham County, Georgia

The National Transportation Safety Board did not travel to the scene of this incident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Burlington, Massachusetts

Aviation Incident Preliminary Report - National Transportation Safety Board:

Location: Savannah, GA
Incident Number: ERA19IA178
Date & Time: 05/09/2019, 1228 EDT
Registration: N744AT
Aircraft: Cessna 550
Injuries:7 None 
Flight Conducted Under:  Part 135: Air Taxi & Commuter - Non-scheduled - Air Medical (Discretionary) 

On May 9, 2019, at 1228 eastern daylight time, a Cessna C550, N744AT, experienced a total loss of engine power to both engines and diverted to Savannah/Hilton Head International Airport (SAV), Savannah, Georgia, where it landed without further incident. Both airline transport pilots, two medical crew, and three passengers onboard were not injured. The flight was operated by Air Ambulance by Air Trek Inc as a Title 14 Code of Federal Regulations Part 135 air medical flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight, which originated from Naples Municipal Airport (APF), Naples, Florida, around 1100 with an intended destination of Niagara Falls International Airport (IAG), Niagara Falls, New York.

The airplane was based at Punta Gorda Airport (PGD), Punta Gorda, Florida. According to fueling records at PGD, on the morning of the incident, the airplane was fueled with 480 gallons of Jet A fuel with a fuel system icing inhibitor (FSII) additive mixed at the time of fueling. Then, the flight crew completed the 47-nautical-mile flight from PGD to APF without anomaly.

According to the pilots, about 1 hour and 20 minutes into the flight from APF to IAG, while cruising at 35,000 ft mean sea level (msl), the pilot-in-command was trying to set the N1 speed around 103%, but moments after adjusting power, the N1 speed would decrease. Following a few repeated occurrences of the N1 speed decreasing in this manner, all the engine gauges "read regular," then the left engine began to "spool down very slowly." After unsuccessfully attempting to recover engine power, the crew requested a lower altitude from air traffic control and began a descent with the left engine at idle power. The pilot-in-command then noticed that the left engine displayed no oil pressure and subsequently shut it down.

Several minutes passed as the airplane descended with the right engine at 65% fan speed, and while preparing to perform a single-engine approach into SAV, about 8,000 ft msl, the right engine became unresponsive and then began "spooling down." The pilot-in-command declared an emergency and the flight crew performed a straight-in approach to runway 19. The airplane landed without incident and was towed to the ramp.

The second-in-command noted that the left fuel filter bypass light did not illuminate but that the right fuel filter bypass light did illuminate.

According to a lineman who worked for the fixed based operator at PGD, the evening before the incident, he noticed that the FSII was low on a fuel truck and he intended to refill it. He went to a shed where the FSII was located and noted that the FSII bottle was partially filled, and that there was another bottle next to it that was partially filled. He combined the two bottles and then refilled the fuel truck FSII reservoir. Several days after the incident, the lineman realized that he had inadvertently combined a 5-gallon FSII bucket and a 2.5-gallon diesel exhaust fluid (DEF) container instead of two partially-empty containers of FSII.

Fuel samples, fuel system filters, and fuel screens from the airplane were obtained and sent for laboratory testing. Analysis of the fuel contaminants indicated the presence of urea, the primary chemical found in DEF.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N744AT
Model/Series: 550 No Series
Aircraft Category: Airplane
Amateur Built: No 
Operator: Air Ambulance By Air Trek Inc
Operating Certificate(s) Held: On-demand Air Taxi (135)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day 
Observation Facility, Elevation: SAV, 51 ft msl
Observation Time: 1653 UTC
Distance from Accident Site: 0 Nautical Miles
Temperature/Dew Point: 26°C / 19°C
Lowest Cloud Condition: Few / 2700 ft agl
Wind Speed/Gusts, Direction: 12 knots / , 120°
Lowest Ceiling: Broken / 3200 ft agl
Visibility:  10 Miles
Altimeter Setting: 30.1 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Naples, FL (APF)
Destination: Niagara Falls, NY (IAG)

Wreckage and Impact Information

Crew Injuries: 4 None
Aircraft Damage: None
Passenger Injuries:3 None 
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion:  None
Total Injuries: 7 None
Latitude, Longitude: 32.129167, -81.200833 (est)


  1. Holee CRAP!!! KUDOS to the pilots!!! Great Job!!!

  2. My hat is off to BOTH pilots for dead-sticking a Citation in for a successful landing. This DEF should be kept miles from any aviation fuels or additives. This kind of thing shouldn't happen. Just like fueling a piston engine with Jet A only to have the engine blow on climb-out at the worst possible time! Yikes.

  3. Congratulations! Air Trek just got two engines valued at $500k. The FBO will get to retrain all their line service personnel in English rather than Spanish like before.

  4. The def fluid damages the aircrafts entire fuel system along with the engines. This type of contamination occurs often on diesel pickup trucks that require def. Once in awhile, it gets poured into the fuel tank by the owner, instead of def tank. The truck quit running after being driven 15 miles. It costs upwards of $20,000 to repair the damage on a newer Dodge. On a plane such as this, it is possibly a total by the insurance company due to type of aircraft. Glad they got the Air ambulance on the ground with no injuries. A pilot to admire.

  5. DEF did its job. It lowered emissions

  6. Any other planes refueled with that bad mix from the same truck?
    Can the truck be cleaned, or is the refueling system trashed?
    Failure to pay full time and attention to your duty can be disastrous in so many endeavors.


  7. This beats all I've ever heard. Dad blame!

  8. This same error with DEF and Jet fuel additive also occurred a couple years ago at Omaha NE.
    Lear Jet crew had the excitement of a dual flame-out and dead stick landing at Lincoln NE.
    Couple of Miitary aircraft toasted their engines and even some poor bastard in a King Air that was nice enough to by 50 gallons of courtesy fuel got screwed. No good deed...,

    16 aircraft (FAA Report) in all affected to various degrees. It would be nice to have an EPA exemption/waiver for Airport support/service trucks not to be required to burn DEF. that may keep this out of the line department building.

    I'm sure this will finally be addressed once there are fatalities. Hope our Flight Dept never is put to the "Test" in this manner.
    Fly Safe

  9. These pilots should be recognized by Air Tek, the FAA and the public. I’m sure it was very intense on the flight deck but my hat is off to this flight crew for being what every pilot aspires to be. True professionals.
    This story is frightening but oh so real. Great job.

  10. Easy solution, add a die to it like off road fuel. Done no more confusion by ground crews.