Accident at Jacksonville, Florida, 15 Oct 1959 (N-4000A)

Accident narrative

On October 15, 1959, at approximately 2105 e.d.t., a U.S. Overseas Airlines C-54-G cargo flight ditched in a small lake near the U.S. Naval Air Station in Jacksonville, Florida. The aircraft caught fire and sank in 10 feet of water approximately eight minutes after takeoff. The two pilots, who were the only occupants aboard, were seriously injured.

### The flight

The aircraft, registration N 4000A, was operating a "Quicktrans" scheduled U.S. Navy contract cargo flight that had originated in Oakland, California, the previous day. A new crew, Captain Jewell Reid and Copilot Gordon Cole, took over the aircraft at Jacksonville for a flight to Marine Corps Air Station Cherry Point, North Carolina, with a scheduled stop at Charleston, South Carolina.

Captain Reid had 12,166 total flying hours, including 7,303 hours in C-54 aircraft. Copilot Cole had 9,024 total flying hours, with 255 hours in C-54s.

During the preflight check, the aircraft was refueled. Only the main fuel tanks were filled, bringing them to a total of 951 gallons. The four auxiliary fuel tanks were not serviced; aircraft records indicated they contained between 25 and 50 gallons each. The captain drained the fuel tank sumps and observed no evidence of contamination. The gross weight at takeoff was 66,501 pounds, which was 7,299 pounds under the allowable maximum.

The recorded weather at departure was broken clouds at 2,500 feet and a 10,000-foot overcast, with visibility of three miles in fog and smoke. The captain later stated that the actual weather was scattered clouds with unlimited visibility and a fully visible moon, while a U.S. Navy aircraft circling the wreckage reported broken clouds at an estimated 3,000 feet and 10 miles visibility.

### The emergency

The flight departed runway 090 at 2057. The crew stated that the takeoff and initial climb were routine. Upon reaching approximately 1,400 feet, the No. 4 engine surged. The throttle was retarded and advanced, but surging continued and manifold pressure fell. The crew observed fluctuating fuel pressure and fuel flow on the No. 4 engine, though no fuel warning light was seen. Applying carburetor heat and selecting the low and high fuel booster pumps did not improve the condition.

At 2101, the flight advised FAA Imeson Airport departure control of the No. 4 engine trouble and received permission to circle east of the Naval Air Station at 1,500 feet. At 2103, the flight requested a radar vector back to the station and was instructed to turn to a heading of 275 degrees. Subsequent clearances were not acknowledged by the pilot.

As the pilot initiated a left turn toward the suggested heading, the No. 4 cylinder head temperature decreased. The captain closed the cowl flaps and decided to feather the propeller, but deferred this action when the No. 3 engine began to surge. He called for METO power, which could not be obtained. Approximately five seconds later, the No. 2 engine began surging.

During the emergency, the copilot stated, "I think we must have taken on jet fuel. It acts like a C-46 did when they were given jet fuel." The copilot reached over and checked the position of the fuel selectors, though the captain did not remember whether they were moved. The crew did not notice the engine instrument readings after the initial No. 4 engine difficulty, nor did they notice whether there was a loss of power from the No. 1 engine.

Descending rapidly, the crew attempted to ditch on a small lake directly ahead. The aircraft struck several trees and hit the water wings level in a tail-low attitude. The radar blip disappeared at 2105.

### What the investigation found

The aircraft came to rest with approximately 80 percent of the fuselage submerged. Fire consumed the upper fuselage.

Investigators found the fuel tank selector valves in the auxiliary tank positions. Examination of the fuel lines, screens, filters, and pumps revealed no restrictions in fuel flow and no evidence of mechanical malfunction, failure, or fire prior to impact. There was no evidence of crew incapacitation.

The investigation explored the crew's suspicion of contaminated fuel. Laboratory analyses of fuel samples and an investigation of the airport's fuel handling completely eliminated the possibility of improper or contaminated fuel.

U.S. Overseas Airlines operated both 6-tank and 8-tank C-54 aircraft, which featured different fuel selector positions. On the 6-tank system, the forward position selected the main tanks. On the 8-tank system installed on N 4000A, the center position selected the main tanks, while the forward position selected the auxiliary tanks. Placards on the instrument panel warned crews to take off on the main tanks.

The Board's analysis indicated that the accident resulted from fuel exhaustion due to positioning the fuel selectors to the virtually empty auxiliary tanks prior to takeoff. The 25 to 50 gallons of fuel in each auxiliary tank was sufficient to take off and reach the accident site. The Board concluded that the copilot mistakenly considered himself to be in a 6-tank aircraft; believing the forward positions were correct for the main tanks, he merely ensured the selectors were in the forward detents during the emergency.

The Board believed that while it was not unreasonable for the captain to consider improper fuel as a reason for the power loss, it should not have been accepted to the exclusion of fuel starvation. The fluctuating fuel pressure and flow, combined with low cylinder-head temperatures that eliminated the possibility of jet fuel, should have alerted the captain to the actual difficulty. The Board noted that switching fuel selectors to another tank should normally be one of the first acts after a sudden decrease in fuel pressure and flow, and that the captain had four or more minutes to analyze the problem before impact.

Following the accident, the airline blocked off the No. 2 and No. 3 tank selectors from the auxiliary positions on all 8-tank aircraft, installed placards directly in front of the selectors stating the fuel system type, and revised its checklist responses.

### Probable cause

The Board determined that "the probable cause of this accident was incorrect fuel system management, resulting in a power loss in three engines."