1

AAIPU# A10-01312

AIR ACCIDENT INVESTIGATION 

AND PREVENTION UNIT

CIVIL AVIATION DEPARTMENT

NASSAU, N. P., BAHAMAS

AIRCRAFT ACCIDENT REPORT

LOSS OF CONTROL & UNCONTROL FLIGHT INTO TERRAIN

ACKLINS BLUE AIR CHARTER

CESSNA 402C

C6-NLH

LAKE KILLARNEY, NASSAU, N.P., BAHAMAS

OCTOBER 5, 2010
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 2

Bahamas Department of Civil Aviation

Air Accident Investigation and Prevention Unit

P. O. Box AP-59244

Lynden Pindling International Airport

Nassau N. P., Bahamas

AIRCRAFT ACCIDENT REPORT

CESSNA 402C

C6-NLH

LOSS OF CONTROL & UNCONTROLLED FLIGHT INTO TERRAIN

LAKE KILLARNEY, NASSAU, N. P., BAHAMAS

OCTOBER 5, 2010

Abstract: This report outlines the circumstances involving the accident of Lebocruise Air Limited [Acklins Blue Air 

Charter

1

] aircraft C6-NLH, a Cessna 402C aircraft which crashed shortly after becoming airborne from Runway 14 at Lynden 

Pindling International Airport into Lake Killarney, Nassau, Bahamas on October 5, 2010. Safety and security issues in this

report addresses the use of unauthorized air charter operators, inadequate pilot training, inadequate security procedures at 

Fixed Based Operations, inadequate aircraft maintenance, CAD oversight and surveillance of unauthorized / non-certified 

commercial air transportation operations, weight and balance and non compliance with search and rescue requirements.

 

1 Acklins Blue Air Charter is not a Bahamas recognized Air Taxi Operator
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 3

Bahamas Department of Civil Aviation

Air Accident Investigation and Prevention Unit

The Air Accident Investigation and Prevention Unit (AAIPU) is a unit within the Flight Standards Inspectorate 

(FSI), the regulatory unit of the Bahamas Civil Aviation Department (BCAD).

The AAIPU‟s function is to promote and improve safety and public confidence in the aviation industry through 

excellence in: 

 independent investigation of aviation accidents and other safety occurrences 

 safety data recording, analysis and research 

 fostering safety awareness, knowledge and action. 

The AAIPU does not investigate for the purpose of apportioning blame or to provide a means for 

determining liability. 

The AAIPU performs its functions in accordance with the provisions of the Bahamas Civil Aviation (Safety) 

(Amendment) Regulations (CASAR) 2010, Schedule 19, International Civil Aviation Organization (ICAO) Annex 

13 and, where applicable, relevant international agreements. 

The Flight Standards Inspectorate established in 2001, is mandated by the Ministry of Tourism and Aviation to 

investigate air transportation accidents and incidents, determine probable causes of accidents and incidents, issue 

safety recommendations, study transportation safety issues and evaluate the safety effectiveness of agencies and 

stakeholders involved in air transportation.

The AAIPU makes public its actions and decisions through accident reports, safety studies, special investigation 

reports, safety recommendations and safety alerts. When the AAIPU issues a safety recommendation, the person, 

organization or agency must provide a written response within 90 days. That response must indicate whether the 

person, organization or agency accepts the recommendation, any reasons for not accepting part or all of the 

recommendation, and details of any proposed safety action to give effect to the recommendation.

Copies of accident reports can be obtained by contacting:

Captain Patrick L. Rolle

Director

Bahamas Department of Civil Aviation

P. O. Box N975

Nassau N. P., Bahamas

(242) 326-0339/40
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 4

Bahamas Department of Civil Aviation

Air Accident Investigation and Prevention Unit

Table of Contents

GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT........................................................... 8

DEFINITIONS ...................................................................................................................................... 9

TITLE.................................................................................................................................................. 11

SYNOPSIS.......................................................................................................................................... 12

1.0 Factual Information:.................................................................................................................. 14

1.1 History of the Flight ................................................................................................................. 14

1.1.0 Background ....................................................................................................................... 14

1.1.1 Early Morning Activity...................................................................................................... 14

1.1.2 Accident Flight Preparations.............................................................................................. 15

1.1.3 Ground Maneuvers............................................................................................................ 15

1.1.4 The Take-off...................................................................................................................... 15

1.1.5 Eyewitnesses Evidence ...................................................................................................... 16

1.2 Injuries to Persons.................................................................................................................... 18

1.3 Damage to Aircraft................................................................................................................... 18

1.4 Other Damage .......................................................................................................................... 18

1.5 Personnel Information .............................................................................................................. 19

1.5.1 Pilot............................................................................................................................... 19

1.5.2 Second Pilot................................................................................................................... 19

1.6 Aircraft Information ................................................................................................................. 20

1.6.1 General.............................................................................................................................. 20

1.6.2 Aircraft Description........................................................................................................... 20

1.6.3 Engines.............................................................................................................................. 20

1.6.4 Propellers .......................................................................................................................... 21

1.6.5 Flight Controls................................................................................................................... 21

1.6.6 Aircraft Fuel System.......................................................................................................... 22

1.6.7 Weight and Balance........................................................................................................... 22

1.6.8 Weighing Report ............................................................................................................... 23

1.6.9 Limitations ........................................................................................................................ 23

1.6.9.1 Operating Speeds ..................................................................................................... 23

1.6.10 Maintenance History of the Aircraft................................................................................. 23

1.6.11 Maintenance History of the Left Engine and Propeller ..................................................... 23

1.6.12 Maintenance history of the Right Engine and Propeller.................................................... 24

1.7 Meteorological Information...................................................................................................... 24

1.8 Aids to Navigation ................................................................................................................... 25
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Final Report C6-NLH Page 5

1.9 Communications ...................................................................................................................... 25

1.10 Aerodrome Information.......................................................................................................... 25

1.10.1 Nassau Airport Development Company (NAD) .............................................................. 25

1.10.2 Aircraft Rescue and Firefighting ..................................................................................... 26

1.10.3 Air Traffic Control......................................................................................................... 26

1.11 Flight Recorders..................................................................................................................... 26

1.12 Wreckage and Impact Info..................................................................................................... 26

1.12.1 General Wreckage Description ........................................................................................ 26

1.12.2 Fuselage .......................................................................................................................... 28

1.12.3 Engines and Propeller ...................................................................................................... 28

1.12.4 Wings.............................................................................................................................. 28

1.12.5 Empennage and Flight Controls....................................................................................... 29

1.12.6 Damage to Seats and Cabin Floor ................................................................................... 29

1.12.7 Fuel Selection.................................................................................................................. 30

1.12.8 Left Console Panel........................................................................................................... 30

1.13 Medical and Pathological ....................................................................................................... 32

1.14 Fire......................................................................................................................................... 32

1.15 Survival Aspects..................................................................................................................... 32

1.15.1 First Aid .......................................................................................................................... 32

1.15.2 Fire Service and Emergency Response............................................................................. 33

1.16 Tests and Research ................................................................................................................. 34

1.16.1 #2 Cylinder Analysis: ..................................................................................................... 34

1.16.2 Left Engine Analysis ...................................................................................................... 34

1.16.3 Right Engine Analysis .................................................................................................... 34

1.16.4 Human Factors Research and Analysis ........................................................................... 34

1.16.5 Weight and Balance Scenarios .................................................................................... 34

1.16.6 Flying over Gross Weight ............................................................................................... 36

1.16.7 Airplane Performance ................................................................................................. 37

1.17 Organizational and Management Information ......................................................................... 37

1.18 Additional Information....................................................................................................... 37

1.18.1 Acklins Blue Air Charter ................................................................................................ 37

1.18.2 CAD Oversight of Acklins Blue Air Charter...................................................................... 37

1.18.5 Performance Category .................................................................................................... 38

1.18.6 Emergency Procedures.................................................................................................... 38

1.18.7 Pre accident CAD Actions.............................................................................................. 38

1.18.8 Post Accident Recommendations / Safety Alerts Issued .................................................. 39

1.18.9 Post accident Airport Authority Actions.......................................................................... 39

1.18.10 Post accident CAD /FSI Actions................................................................................. 39

1.18.11 Post accident EFS Actions........................................................................................... 40

1.18.12 Post accident NAD Actions......................................................................................... 40

2.0 Analysis.................................................................................................................................... 41

2.1 Overview.................................................................................................................................. 41

2.1.1 Flight reconstruction .......................................................................................................... 41

2.1.2 Wreckage Analysis.............................................................................................................. 42

2.1.3 The Initiating Event............................................................................................................. 42

2.2 Other Factors............................................................................................................................ 43

2.2.1 Aircraft Loading ................................................................................................................ 43

2.2.2 Pre-take-off Events............................................................................................................ 43
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2.2.3 Flap Position...................................................................................................................... 44

2.3 Event Timing ........................................................................................................................... 44

2.4 Before the Initiating Event........................................................................................................ 44

2.4.1 The Take-off...................................................................................................................... 44

2.4.2 The Initial Climb ............................................................................................................... 45

2.5 The Initiating Event.................................................................................................................. 45

2.5.1 The position of the aircraft when the misfiring was heard............................................... 45

2.6 Practical engine failure identification................................................................................. 46

2.7 Events between the initiating event and the left turn............................................................... 46

2.7.1 Control of Bank Angle....................................................................................................... 46

2.7.2 Climb Performance............................................................................................................ 46

2.8 Condition of the engine in flight ............................................................................................... 47

2.8.1 Right Engine................................................................................................................. 47

2.8.2 Operating the wrong propeller lever............................................................................... 47

2.9 Events during the Turn ............................................................................................................. 47

2.9.1 Loss of Control ........................................................................................................... 48

2.10 The loss of power from the left engine................................................................................ 48

2.10.1 Summary of left and right Engine Analysis........................................................................ 48

2.10.2 Left Hand Engine No. 2 Cylinder Analysis ..................................................................... 49

2.10.3 Left Engine Serial Number 248270 Analysis .................................................................. 55

2.10.4 Right Engine Serial Number 290209 Analysis ................................................................ 58

2.11 Training and testing for pilots of light piston engine aircraft ............................................... 61

2.11.1 The forced landing option ............................................................................................... 61

2.11.2 The pilot‟s decision to return ........................................................................................... 61

2.11.3 Engine failure training and testing in light twin engine aircraft ....................................... 62

2.12 The Implications of Performance Category C ......................................................................... 63

2.13 ATC Tower Controller ........................................................................................................... 63

2.14 Survivability........................................................................................................................... 63

2.14.1 Aircraft Seating .............................................................................................................. 63

2.15 Situational Awareness........................................................................................................ 64

2.16 CAD Oversight....................................................................................................................... 64

2.17 Summary............................................................................................................................ 65

3.0 Conclusions.................................................................................................................................. 66

(a) Findings................................................................................................................................. 66

(b) Causal Factors ....................................................................................................................... 68

4.0 Recommendations:....................................................................................................................... 69

5.0 APPENDICES: ......................................................................................................................... 71

Appendix 5.1 Cylinder Factual Report (NTSB).............................................................................. 71

Appendix 5.2 Left and Right Engine Factual Report (TCM)........................................................... 72

Appendix 5.3 Acklins Blue Companies.......................................................................................... 73

Appendix 5.4 Acklins Blue Air Charter......................................................................................... 73

Appendix 5.5 Acklins Blue Air Charter......................................................................................... 74

Appendix 5.6 ATC tower transcript............................................................................................... 75

Appendix 5.7 Flight Plan Form ...................................................................................................... 76

Appendix 5.8 Fuel Uplift Slip ........................................................................................................ 77

Appendix 5.9 Alert Issued.............................................................................................................. 78

Appendix 5.10 Engine Failure after Take-off Checklist .................................................................. 80

Appendix 5.11 Crash Aircraft Diagram.......................................................................................... 81
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Final Report C6-NLH Page 7

Appendix 5.12 Reference Aircraft Diagram.................................................................................... 81

Appendix 5.13 CASR Regulation Part X, Regulation 67. ............................................................... 82

Appendix 5.14 CASR Regulation Part X, Regulation 68 ................................................................ 82

Appendix 5.15 Aerodrome Chart Nassau, Bahamas........................................................................ 83

Appendix 5.16 Aeronautical Information Circular 100/2005 .......................................................... 84

Appendix 5.17 Cessna 402C Dual Manifold Pressure Gauge............................................................ 85

Appendix 5.18 Alert SA/A10-01312/002/10-9-10 Historical Information........................................ 86

Appendix 5.19 CRASH SITE DIAGRAM.................................................................................... 88

Figure 1 and 2 C6-NLH Pre and Post Accident ................................................................................................ 16

Figure 3 Eyewitness account of the accident .................................................................................................... 17

Figure 4 C402C Seating diagram ..................................................................................................................... 20

Figure 5 Fuselage post accident........................................................................................................................ 28

Figure 6 Left Console ...................................................................................................................................... 30

Figure 7 Actual console Panel for C6-NLH...................................................................................................... 31

Figure 8 Fuel Selector Valves Left and Right Engine ....................................................................................... 31

Figure 9 Power Quadrant ................................................................................................................................. 31

Figure 10 Center of Gravity Graph / Envelope ................................................................................................... 35

Figure 11 Normal Take-off Distance................................................................................................................ 44
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Final Report C6-NLH Page 8

GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT

When the following terms are used in this report, they have the following meanings;

AAIPU Air Accident Investigation and Prevention Unit

AEC Airmotive Engineering Corporation, A division of Danbury Aerospace

ADDS Aviation Digital Data Service - Report by Meteorological Department

AGL/agl Above ground level

AOC Air Operator Certificate Holder

ARFF Airport Rescue and Fire Fighting Service

ATC / ATS Air Traffic Control / Air Traffic Services

AVGAS Aviation Gasoline

CAD Civil Aviation Department

CASR Bahamas Civil Aviation (Safety) Regulations (April 17, 2001)

CMI Continental Motors, Inc., formerly Teledyne Continental Motors

C of A Certificate of Airworthiness

C of R Certificate of Registration

CG Center of Gravity

DAS Danbury Aerospace

Deg /  Degrees

DCA Director of Civil Aviation

DST Daylight Savings Time (+4 hours to convert to UTC)

ECi Engine Components, Inc., a division of Danbury Aeropsace

EOC Emergency Operations Center

EFS Executive Flight Support

FAA Federal Aviation Administration

FBO Fixed Base Operator / Operation

FSI Flight Standards Inspectorate

FSS Flight Service Station

g Gravity at standard sea level

ICAO International Civil Aviation Organization

KIAS knots indicated airspeed

kt Knot(s)

LBS/lbs Pounds

MYNN Lynden Pindling International Airport

MET Meteorological Office / Department

METAR Weather Report furnished by Meteorological Department

MTOW Maximum take-off weight

MYNN ICAO identifier for Lynden Pindling International Airport Nassau, Bahamas

MYSM Cockburn Town, San Salvador Int‟l Airport

NAD Nassau Airport Development Company

NM or nm Nautical Miles

NTSB National Transportation Safety Board

PMH Princess Margaret Hospital

RBDF Royal Bahamas Defense Force

RBPF Royal Bahamas Police Force

SAP Superior Airparts

TRACON Terminal Radar Approach Control

USA/US United States of America

VFR Visual Flight Rules

VMC Visual Meteorological Conditions

UTC / Z Universal Coordinated Time / Zulu time 
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 9

DEFINITIONS

When the following terms are used in this report, they have the following meanings as per CASR 2001 and ICAO 

Annex 13;

“Aircraft Accident”– means an occurrence associated with the operation of an aircraft which takes place 

between the time any person boards the aircraft with the intention of flight and all such persons have 

disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial 

damage or the aircraft is missing or completely inaccessible.

"Fatal injury" - means any injury which results in death within 30 days of the accident.

“Flight recorder”-Any type of recorder installed in the aircraft for the purpose of complementing 

accident/incident investigation.

"Incident" - means an occurrence other than an accident, associated with the operation of an aircraft, which 

affects or could affect the safety of operations.

“Investigation”- A process conducted for the purpose of accident prevention which includes the gathering and 

analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, 

the making of safety recommendations.

“Serious injury" - means any injury which:

 Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was 

received;

 Results in a fracture of any bone (except simple fractures of fingers, toes, or nose);

 Causes severe hemorrhages, nerve, muscle, or tendon damage;

 Involves any internal organ; or

 Involves second or third degree burns, or any burns affecting more than 5 percent of the body surface.

 Involves verified exposure to infectious substances or injurious radiation.

“Serious incident” - An incident involving circumstances indicating that an accident nearly occurred.

“State of Design” - The State having jurisdiction over the organization responsible for the type design

“State of Manufacture” - The State having jurisdiction over the organization responsible for the final assembly 

of the aircraft.

Stall - An accelerated stall is a stall that occurs while the aircraft is experiencing a load factor higher than 1 (1g), 

for example while turning or pulling up from a dive. In these conditions, the aircraft stalls at higher speeds than 

the normal stall speed (which always refers to straight and level flight). Considering for example a banked turn, 

the lift required is equal to the weight of the aircraft plus extra lift to provide the centripetal force necessary to 

perform the turn.

"Substantial damage" - means damage or failure which adversely affects the structural strength, performance, or 

flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected 

component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent failings or 

cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and 

damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered 

"substantial damage" for the purpose of this Report.
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Final Report C6-NLH Page 10

September 30, 2011

Captain Patrick L. Rolle

Director

Bahamas Civil Aviation Department

P.O. Box N-975

Nassau, N.P., 

Bahamas

Sir 

I am duty-bound to submit this report on the circumstances of the fatal accident involving C6-NLH, a 

Cessna 402C aircraft, registered in the Bahamas to Lebocruise Air Limited, and operated by Acklins Blue 

Air Charter Ltd2., Nassau, N.P., Bahamas. This accident occurred on October 5, 2010 at 12:36pm local

time (1636 UTC) in waters of Lake Killarney, approximately 1⁄4 mile from the approach end of Runway 

27 at Lynden Pindling Int‟l Airport, Nassau N. P., Bahamas.

This report is submitted pursuant to Part XII, Regulation 80, and Schedule 19 of the Bahamas Civil 

Aviation (Safety)(Amendment) Regulation (CASR 2010) and in accordance with Annex 13 to the 

Convention on International Civil Aviation Organization (ICAO).

In accordance with Annex 13 to the Convention on International Civil Aviation (ICAO), and Schedule 

19 of the Bahamas Civil Aviation (Safety)(Amendment) Regulations (CASAR), the fundamental 

purpose of such investigations is to determine the circumstances and causes of these events, with a view 

to the preservation of life and the avoidance of similar occurrences in the future. It is not the purpose of 

such investigations to apportion blame or liability.

This report contains facts which have been determined up to the time of publication. Information is 

published to inform the aviation industry and the public of the circumstances surrounding this accident. 

The contents of this report may be subjected to alterations or corrections if additional factual 

information becomes available.

Regards

Delvin R. Major

Investigator in Charge

Air Accident Investigation and Prevention Unit

Bahamas Department of Civil Aviation

Lynden Pindling International Airport

Nassau, N. P., Bahamas 

 

2 Acklins Blue Air Charter was not a Bahamas recognized Air Taxi Operator
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 11

BAHAMAS CIVIL AVIATION DEPARTMENT

AIR ACCIDENT INVESTIGATION AND PREVENTION UNIT

TITLE

Registered Owner: Lebocruise Air Limited

Operator: Acklins Blue Air Charter / Nelson Hanna

Manufacturer: Cessna Aircraft Company

Aircraft Type: Cessna Model 402C

Nationality: Bahamas

Registration: C6-NLH

Place of Accident: In waters of Lake Killarney, approximately 1⁄4 mile from the approach end of 

Runway 27 (MYNN) of Lynden Pindling International Airport, Nassau, Bahamas

Date and Time: October 5, 2010 at 1636 UTC (12:36pm DST)

Notification: DCA, NTSB, ICAO, FAA, Cessna Aircraft Company and Continental Motors, 

Inc., formerly Teledyne Continental Motors

Investigating Authority: Civil Aviation Department

Air Accident Investigation and Prevention Unit

Investigator in Charge: Delvin R. Major

Accredited Representatives: Mr. Tim Monville – NTSB 

Mr. Derek Nash – NTSB

Technical Advisors: Mr. Randall S. Mainquist – Cessna Aircraft Company.

Mr. Rodney Martinez – Continental Motors Inc.

Mr. James Jelinski – FAA

Mr. James L. Tubbs – Danbury Aerospace [ECi cylinder manufacturer]

Releasing Authority: Director of Civil Aviation Department, Nassau, N. P., Bahamas

Date of Draft Report Publication: July 7, 2011
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 12

SYNOPSIS

On October 5, 2010 about 1636 UTC / 12:36pm Eastern Daylight Time (EDT), C6-NLH a Cessna 402C aircraft 

registered to Lebocruise Air Limited and operated by Acklins Blue Air Charter/Nelson Hanna crashed into lake 

Killarney shortly after becoming airborne from runway 14 at Lynden Pindling International Airport, Nassau, New 

Providence, Bahamas. The airplane sustained substantial damages by impact forces. The pilot, copilot and seven 

(7) passengers aboard the airplane received fatal injuries. The aircraft was on a passenger carrying flight from 

Lynden Pindling Int‟l Airport (MYNN) to Cockburn Town, San Salvador, Bahamas (MYSM). The aircraft was 

on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

The official notification of the accident was made to the Manager of the Flight Standards Inspectorate at Lynden 

Pindling Int'l Airport, Nassau, N. P., Bahamas shortly thereafter. The investigation began the same day at 

approximately 1655 UTC upon notification of the IIC. The investigation was conducted by the Bahamas Civil 

Aviation Department [BCAD], Inspector Delvin R. Major (Investigator-in-Charge) of the Air Accident 

Investigation and Prevention Unit (AAIPU), Management of BCAD and Flight Standards Inspectorate (FSI),

Airworthiness Inspectors, Operations Inspectors, Human Factors and other administrative staff. Valuable 

assistance was also received from the National Transportation Safety Board (NTSB), the Federal Aviation 

Administration (FAA) and Manufacturers of the aircraft and engine components.

Three (3) Air Operator Certificate (AOC) holders at the Domestic Section of Lynden Pindling Int'l Airport stated 

that on the day of the accident flight; one of the victims of the accident aircraft approached each of them

individually at different times, requesting a quote and their availability to conduct a charter flight to Cockburn 

Town, San Salvador, Bahamas. 

Each AOC holder reported that they declined to conduct the charter because by looking at the amount of luggage 

and other equipment that accompanied the passengers and the size of the passengers that wanted to travel, in their 

estimation the combined weight appeared to be in excess of the weight that their respective aircraft (Cessna 402C 

and Hawker Beechcraft B100) can accommodate. After the AOC holders declined to conduct the charter,

sometime thereafter, the same individual that was arranging the flight with the previous AOC holders made 

contact with Nelson Hanna / Acklins Blue Air Charter where arrangements were made to conduct the charter

flight. 

The aircraft type certificate allowed for the aircraft to be operated by one (1) pilot, but the fatal flight was 

operated by a crew of two (2) pilots (according to eyewitness reports). The aircraft actual weight and center of 

gravity was unknown. As far as could be determined, the takeoff weight exceeded the maximum weight allowed 

of 6,850 pounds by more than 500 pounds. This excess in weight also placed the center of gravity of the aircraft 

outside of the safe envelope / limits for flight allowed by the manufacturer. 

The flightcrewt was given instructions by ATC to taxi from the business aviation apron (Executive Flight 

Support) for a takeoff on Runway 14 at intersection Foxtrot. (Intersection Foxtrot is 2,000 feet beyond the 

threshold of Runway 14, with a take-off run available of 9,353 feet. (Runway 14 - 11,353 feet long by 150 feet 

wide, see Appendix 5.15).

According to eyewitness reports, from the initiation of takeoff power up to the point when the aircraft lost control 

white smoke was observed trailing behind the left engine of the aircraft. Eyewitnesses also reported that the take 

off appeared normal with gear being retracted shortly after takeoff and the aircraft seemed to be struggling to 

climb. The aircraft was seen at a low height, turning in a left direction over the lake as if trying to return for a 

landing at the airport. The bank of the aircraft changed from shallow to very steep to almost perpendicular to the 

ground, gears were extended and almost immediately the aircraft lost control and nose dived into the lake 

inverted. It cart wheeled, coming to rest upright, approximately 1⁄4 mile from the approach end of runway 27. The 

aircraft came to rest on an approximate heading of 210 degrees.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 13

Eyewitness also reported hearing the engine run for a few seconds after the aircraft made contact with the water of 

the lake. There were no reports from the pilot to ATC of an emergency or any abnormalities with the aircraft or 

its systems after takeoff.

The flight plan form filed for this flight listed one (1) soul on board; however, there were 7 additional occupants 

including a “second pilot” discovered onboard the accident flight the day of the accident. The aircraft‟s recovery 

and search for luggage, equipment and additional victims commenced shortly after the accident. This effort 

however, was hampered by inclement weather, rough lake conditions and darkness. On October 6th, the day after 

the crash, aircraft recovery continued. Family members of an additional person believed to be on board, advised 

the authorities that there was a ninth (9th) person on board. Search to recover any additional bodies continued but 

search and recovery efforts proved fruitless. On October 7th, the second day after the crash, the body of the ninth 

(9th) victim was found in the marshes and recovered from the southwestern end of the lake in the vicinity of where 

the fatal crash occurred.

The investigation identified the following causal factors:

The left engine of C6-NLH suffered a mechanical failure of the #2 cylinder, and therefore could not produce rated 

shaft horsepower. No indication of total loss of power with the left engine reported. 

The electrical and engine control switches for the right engine of C6-NLH were found in the “OFF” position;

therefore the aircraft was incapable of climbing on the power of one engine alone.

The excess weight above the maximum weight allowed for takeoff may have been an important factor in the 

aircraft‟s inability to gain adequate altitude after takeoff. 

Previous discrepancies existed with the left engine not producing power when required to which both pilots were 

made aware prior to the accident flight.

A total loss of thrust occurred once the right engine was secured and a steep turn was initiated with gear down and 

the left engine already developing insufficient shaft horsepower to sustain lift.

The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the left.

Several safety and security recommendations were made during the course of this investigation.
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Final Report C6-NLH Page 14

1.0 Factual Information:

1.1 History of the Flight

On Tuesday October 5, 2010 at 12:36 EDT (1636 UTC3) a fixed wing, twin-engine, Cessna 402C aircraft

Bahamas registration C6-NLH, serial number 402C 0458, crashed into waters of Lake Killarney shortly after 

becoming airborne from runway 14 at Lynden Pindling International Airport (MYNN), Nassau, New Providence, 

Bahamas. The pilot, second pilot and seven (7) passengers on board were fatally injured. The airplane sustained 

substantial damage as a result of the impact and post impact crash sequence. The crash occurred at approximate 

coordinates 28 ̊ 02.218‟N and 077 ̊ 27.150‟W. The passenger carrying flight departed at 12:35 EDT (1635 UTC). 

The destination was Cockburn Town, San Salvador, Bahamas. The flight was operated on a Visual Flight Rules 

(VFR4) flight plan. Visual meteorological conditions (VMC) prevailed at the time of the accident. This was the 

second flight of the day for the aircraft and crew. This flight was a charter flight conducted by an operator that 

was not recognized / authorized by the Bahamas to perform charter work.

1.1.0 Background

The pilot and copilot‟s duty or other activities up to 24 hrs prior to the accident, with the exception of the flight 

that took place prior to the accident flight, is unknown. The aircraft remained in the open air on the business 

aviation ramp at Lynden Pindling Int‟l Airport where it is normally parked. Although the aircraft was certified for 

single-pilot operation, it was reported that there was a crew of two Bahamian pilots on the accident flight. It was 

reported that the pilot (Mr. Hanna) operated a significant portion of flights himself; however, the same pilot often 

accompanied him as his co-pilot. The co-pilot was qualified to fly the generic group of aircraft to which C6-NLH 

belonged, but he was not qualified to operate revenue flights in a 402C as a single pilot. He had not undergone the 

requisite type specific checks and test. As he was “time-building” his duties should have been chiefly to assist the 

pilot with radio telephony and administration; consequently, a more appropriate description for his role was 

„second pilot‟. 

After returning to Nassau, arrangements were made for Acklins Blue Air Charter to fly passengers and their 

luggage and equipment to San Salvador, Bahamas. This was the flight that crashed resulting in nine fatalities. 

After loading the aircraft with passenger and luggage the aircraft obtained ATC clearance for VFR departure 

before taxiing from the Fixed Based Operation (FBO), Executive Flight Support (EFS). 

1.1.1 Early Morning Activity

On the morning of the October 5, 2010 at 8:45am, C6-NLH was fuelled with 80 gallons of aviation gasoline 

(avgas) by Executive Flight Support. (See Appendix 5.8). A flight plan was filed to Treasure Cay, Abaco, 

Bahamas. The flight plan form listed two (2) souls on board. (It was later revealed that there were in fact six (6) 

souls on board for that flight). At approximately 9:30 am, the pilot conducted that charter flight from Lynden 

Pindling Int‟l Airport to Treasure Cay, Abaco, Bahamas (the flight prior to the accident flight).

One of the passengers of that flight (who holds a USA Airline Transport Pilot rating [ATP]) reported that he paid 

Mr. Hanna to conduct a charter flight to Treasure Cay, Abaco, Bahamas. The same passenger reported that he sat 

in the seat behind the co-pilot (seat #4) and he observed technical problems with the aircraft‟s left engine 

manifold pressure gauge needle readings (see Appendix 5.17) during the engine run up exercise at the runway 

prior to take-off. 

 

3 UTC - The 24 hour clock is used to describe the time of day, Coordinated Universal Time (UTC) as particular events occurred.

4 Visual Flight Rules - are a set of regulations which allow a pilot to operate an aircraft in weather conditions generally clear enough to 

allow the pilot to see where the aircraft is going.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 15

The passenger reported that he observed the left engine manifold pressure needle not reacting as it should. There 

was a split (or difference) of approximately 90 ̊ between the left engine and right engine manifold pressure 

reading as evidenced by the manifold pressure gauge needles. The passenger stated that he advised both pilots and

they both shrugged it off as no big deal and said it will clear up once full power is applied. (See Eyewitness 

Evidence 1.1.4)

Having himself been involved in an aircraft incident with the exact type of manifold pressure discrepancy

previously, the passenger stated that he was uneasy. However, the manifold pressure reading eventually came up 

during the take-off roll and the flight departed. The pilot was unable to land the aircraft at his destination of 

Treasure Cay due to bad weather. He eventually diverted and landed at Marsh Harbour International Airport, 

Marsh Harbour, Bahamas instead. (See Eyewitness Evidence 1.1.4) Aside from the enroute weather conditions 

that were encountered, the flight was uneventful. The crew departed Marsh Harbour and returned to Nassau.

1.1.2 Accident Flight Preparations

Sometime after returning from Marsh Harbour, a flight plan for C6-NLH was filed for a flight from Nassau to San 

Salvador, Bahamas. The flight plan form was received by EFS and filed with ATC with a proposed flight time of 

1 hour enroute, at an altitude of 7,500 feet and four (4) hours of fuel endurance. An additional 60 gallons of 

Aviation Gasoline (Avgas) was loaded in the tanks of C6-NLH by Executive Flight Support at 12:06pm. (See 

Appendix 5.8). The flight plan form listed one (1) soul on board. (Post accident, eight (8) bodies were recovered 

from the crash. All occupants received fatal injuries. On Thursday October 8, 2010 two (2) days after the 

accident, a ninth body was recovered from the waters). (See Appendix 5.7 Flight Plan Form).

The crew prepared for their flight without assistance of the EFS staff with the exception of a ramp agent who 

carried and loaded a box weighing approximately 30 pounds on the aircraft. The ramp agent confirmed that the 

co-pilot was the one that loaded the aircraft and he did not see what was loaded in the luggage compartments. He 

further stated that he observed the pilot while at the aircraft make some adjustments to seats 7 and 8 (the double 

seats at the entrance door of the aircraft). (See seating diagram figure 4)Apart from this encounter, no personnel at 

EFS paid much attention to the aircraft or the preflight activities of the crew. 

The passengers gained access to the aircraft through the EFS‟ facility. However, no one at the facility‟s desk knew 

who they were, who took them out to the aircraft or what aircraft they boarded. No personnel at EFS knew who 

boarded the aircraft or where they were seated on the aircraft. No personnel knew if the luggage or equipment was 

weighed or whether or not a weight and balance document was prepared. The crew did not leave a copy of a

weight and balance document with EFS.

1.1.3 Ground Maneuvers

At 16:31 hrs the second pilot*

5

requested ATC clearance for the flight to San Salvador and shortly thereafter 

clearance for taxi to the Foxtrot Intersection of Runway 14. The flight crew was cleared to taxi and to hold short 

of the runway and then to contact Nassau Tower controller.

1.1.4 The Take-off

At 16:35:15 Clearance to take-off was given and the second pilot acknowledged the clearance. While on the takeoff roll and prior to becoming airborne, eyewitnesses observed white smoke trailing behind the left engine of the 

aircraft. Additional witness reported hearing sounds like a misfiring engine and observing intense white smoke

during the take-off, progressively getting worse just after lift-off.

 

5

* The voice recorded on ATC tapes making contact with ATC from taxi through the final transmission to land was not the voice of Mr. 

Nelson Hanna. Luggage handlers at Executive Flight Support confirmed that a co-pilot was on board the aircraft and the co-pilot was 

responsible for loading the aircraft with luggage prior to departure. Post accident investigations revealed that the copilot was a pilot 

employed with the RBDF who was time building. They both had recently just returned from a flight to Treasure Cay, Abaco, Bahamas.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 16

The aircraft appeared to become airborne near intersection of Runway 14 and taxiway Bravo1 and commenced a 

left turn just prior to the intersection of the two runways (27 and 32).

At 16:36:15 ATC tower controller advised the pilot that he needed him to return as there was white smoke trailing 

behind his left engine. The pilot acknowledges and stated they were returning. At 16:36:24 the tower controller 

questioned the pilot if he was able to return and land on runway 27. The copilot of C6-NLH replied in the 

affirmative. The tower controller then approved the pilot to return to runway 27. There were no further recorded 

communications from the flight crew of C6-NLH. The aircraft crashed a short time later. (See Eyewitness 

Evidence 1.1.5 for more information). According to ATC tower tapes and transcription, at no time did the flight 

crew of C6-NLH report an emergency or any abnormalities with any engine or instrumentation.

Figure 1 and 1 C6-NLH Pre and Post Accident

1.1.5 Eyewitnesses Evidence

(All eyewitnesses evidence presented here are from persons in the aviation field and / or knowledgeable of 

aviation procedures and terminology)

A passenger (USA rated airline pilot) who had just chartered the aircraft the morning of the crash stated that while 

the pilots were conducting the run-up checks at the runway, prior to take-off, he observed technical problems with 

the manifold pressure gauge needle readings for the left engine. Concerns were raised with the pilots and he was 

advised that the problem would go away once full power was applied. He stated that the needles of the right and 

left engine manifold pressure gauge were at odds with each other by approximately 90 degree difference (See 

Appendix 5.17). The right needle of the manifold pressure gauge responded appropriately when the power lever 

was manipulated, but the left needle was slow to respond or did not respond at all. Eventually, the needle

indications matched each other and once the pilots were satisfied, the aircraft departed. In addition to the 

discrepancy observed with the engine, navigational instruments in the aircraft, required for instrument 

meteorological conditions (IMC) flight were inoperative. The weather at the time was Instrument Meteorological 

Conditions (IMC). In his opinion, as a professional pilot, the passenger stated that the aircraft was un-airworthy.

A mechanic who was standing on the ramp near Executive Flight Support (EFS) at the time of the crash, told 

investigators that he observed the airplane take off from MYNN on runway 14, heading south. He stated that he 

observed white smoke trailing behind the aircraft. When he “looked at the aircraft again it appeared to be 

experiencing engine trouble”. He observed the aircraft banking to the left with landing gears in the down 

position. He stated he believed the airplane was attempting to land on runway 27, but the aircraft was flying 

abnormal. The witness further stated that he believed the aircraft went into a stall and that is when he believes the 

pilot lost control of the aircraft. He then saw the aircraft flipped upside down and plunged into the lake. He saw 

and heard a loud explosion.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 17

Another eyewitness, who is an ATC ground 

controller, stated “I observed aircraft C6-NLH 

which departed at 1633, with white smoke

trailing behind the left engine. The pilot made 

a left turn attempting to return to the field. It 

was then that I noticed that the aircraft began 

an immediate descent and ditched into waters 

at the approach end of runway 27.”

Another eyewitness, who is a boat captain and 

private pilot, passing on the perimeter road 

near to runway 14/32 stated that he was 

travelling along Coral Harbour road / airport 

perimeter north bound when he observed a 

twin engine airplane departing the runway. The 

aircraft appeared to be lower than normal and 

white smoke was bellowing from the left 

engine. He stated that he thought the odor of 

the white smoke was consistent of aviation 

gas.

The plane intersected his position as it crossed 

the perimeter fence and disappeared from view 

due to the roof of his car. At that time he 

believes the landing gears were up. He was 

again able to see the airplane from his rear 

view window as it crossed the road and began 

to cross Lake Killarney. 

The pilot started a bank over the lake prior to 

lowering the gears. The bank became more 

severe before finally going into a hard over 

and nosing into the water. The witness stated 

he stopped his car and ran in the direction of 

the crash to investigate and help. At this time 

he was on the phone calling 911. He advised 

them of the plane crash. He stated that he was the first on the scene. However, he stayed out of the water due to 

the presence of avgas. He stated that the plane was in the water but it was impossible to tell what attitude it was 

in. It was approximately 300 to 400 yards from his position. It appeared to be fractured into a number of pieces. 

According to the eyewitness, personnel from the airport (NAD) were next arriving on scene followed by 

personnel from the police force. Eventually two persons swam out to the plane and began the rescue prior to his 

departure.

Additionally, an eyewitness who was located on the airport at the time of the accident late stated that the airplane 

became airborne at intersection of runway 14 and taxiway B which in his estimation was a long and late time for 

an aircraft to get airborne. "At rotation the gears were up, like in a normal take-off and white stuff sprayed at 

about 50 feet in climb. I noticed at climb it (aircraft) seemed nose high, and trail of white smoke from left 

engine." "It did not get high, approximately 150 feet" He also stated that "it seemed weird to me, the engine made 

funny sound to me, like he was pulling down on the props, like the power was pulled back." “The aircraft turned 

deep and rolled over to the left. I heard the engine running for about 10 seconds after it hit the water, the engine 

was on, and then stopped."

Figure 2 Eyewitness account of the accident
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 18

Another eyewitness (an aviation technician) who was located on the ramp at MYNN at the time of the accident 

stated that he saw the aircraft taxi out and became airborne in a southeast direction. Approximately 3 - 5 minutes 

after becoming airborne he stated that he could still see white smoke trailing behind the left engine. He also stated 

he saw the aircraft go from a gradual left bank, to a more severe bank. “It began a left steep bank trying to return 

as to land.” “The aircraft went from a normal left turn to a sharp turn; left wing was almost perpendicular to the 

ground.” “There was a sudden flip, like a shift or a jerk to the left as though something opened like a door.” “At 

that point the aircraft continued in a barrel roll nose first, we heard the impact and water splash.”

A pilot who was next in line for takeoff reported that while at the threshold awaiting his takeoff clearance, he 

noticed the aircraft at intersection Foxtrot (C6-NLH) took an unusually long time conducting its pre-takeoff run 

up checks. According to this and other eyewitnesses reports, from the application of power and the initiation of 

the take-off roll, (from intersection Foxtrot), through the take-off, white smoke was observed trailing behind the 

left engine of the aircraft. The aircraft became airborne near the intersection of runway 14 and taxiway Bravo 1. 

The white smoke seemed to get worse after the aircraft became airborne.

Additional eyewitnesses on the field at the time stated, from initiation of the take-off roll, seeing white smoke and 

hearing sounds trailing behind the aircraft which sounded like the aircraft was backfiring. Eyewitnesses further 

stated “the gears were retracted and it appears the aircraft was struggling to climb. The aircraft made a gradual left 

bank increasing to a sharper bank as if trying to return for a landing. The bank continued until the wings were 

almost perpendicular to the ground.” “Gear was extended somewhere in the turn and the aircraft went into a 

barrel roll and crashed into the lake.” Witnesses reported hearing sounds as if the pilot was pulling back on the 

propeller levers just prior to the crash. 

Eyewitnesses‟ stated the aircraft was approximately 150 to 200 feet when all of this occurred. A number of 

eyewitnesses in cars and at the General Aviation Center saw the aircraft after it became airborne. The majority 

were travelling along the airport perimeter road (Coral Harbour Road). They noticed that the aircraft was at a low 

height as it crossed the perimeter road. The aircraft commenced a bank to the left, and increased the bank sharply 

as if trying to return for a landing on runway 27. They saw the aircraft angle increased until it was near vertical 

and then the nose dropped. They saw the aircraft enter a steep dive before disappearing behind trees and into the 

lake.

1.2 Injuries to Persons

1.3 Damage to Aircraft

The aircraft sustained substantial damage due to the impact sequence and subsequent water submersion. It was 

later recovered from the crash site and transported to a secure facility for the field investigation.

1.4 Other Damage

Other than damage sustained by the aircraft and subsequent recovery efforts, no other damage was reported.

Unknown environmental damages may have been sustained by the lake due to the amount of fuel spilled as a 

result of the ruptured fuel tanks.

Injuries Crew Passengers Others Total

Fatal 2 7 0 9

Serious

Minor/None
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 19

1.5 Personnel Information

1.5.1 Pilot

43 yr old Nelson Leo Hanna, a Bahamian of Nassau, Bahamas was listed as the pilot in command on the flight 

plan form filed at EFS. Mr. Hanna was the holder of a valid Bahamas Commercial Pilot Certificate number 392 

CP, issued on 07 October, 1999 with airplane multi-engine land, instrument airplane category and class rating 

with no limitations. Mr. Hanna was the holder of a Bahamas second class medical certificate issued August 04, 

2009. However, he could not exercise the privileges of his commercial pilot license as this second class medical 

certificate expired on August 31, 2010. Mr. Hanna‟s medical certificate held no medical limitations.

Mr. Hanna received a medical examination for renewal of his second class medical certificate (minimum required 

for commercial operations) on September 7, 2010. The medical exam results were submitted to the FSI for 

renewal and reissuance of his second class medical on September 16, 2010. The Second Class Medical was 

processed and authorized shortly thereafter. However, Mr. Hanna had not returned to the FSI to retrieve his 

Second Class Medical certificate up to the time of the accident on October 05, 2010.

He was also the holder of a USA issued commercial pilot license with airplane - multi-engine land, instrument 

privileges and private pilot privileges for airplane - single engine land. Mr. Hanna‟s total flying experience 

recorded on the insurance documents retrieved post accident listed his total civilian flight times as in excess of 

12,000 flight hours. His flying experience on this type of aircraft is listed as in excess of 10,000 hours. Mr. 

Hanna‟s pilot logbook was not made available to investigators therefore an accurate up to date account of his total 

flight time is unknown.

The amount of hours flown by Mr. Hanna in the last 24 hr, 7 days or the last 30 days prior to the accident is 

unknown with the exception of the flight conducted to Marsh Harbour, Abaco on October 5, 2010, the same day 

prior to the accident flight, which accounted for approximately 2 hours. FAA and CAD records indicate there 

have been no violations or prior FAA/CAD recorded aviation accident history or violations against Mr. Hanna. 

No records were made available to the investigation team to verify whether Mr. Hanna had accomplished a 

required proficiency check (required of all pilots engaged in commercial air transportation) within the specified 

time frame stipulated by his insurance policy and CASR Schedule 14.095, 14.120 or 14.180 for commercial 

operations.

1.5.2 Second Pilot

Mr. Devon Storr age 27, acted as a second pilot for the accident flight as well as several previous flights with Mr. 

Hanna. Mr. Storr was the holder of a valid US Commercial Pilot Certificate issued on March 15, 2008, with 

airplane multi-engine land and instrument airplane ratings and also held a Private Pilot Certificate with airplane

single-engine land rating. Mr. Storr was also the holder of a Bahamas Commercial Pilot Certificate number 704

CP, issued on 11 August, 2010 with airplane multi-engine land, instrument airplane category and class rating with 

no limitations. 

Mr. Storr was also the holder of a valid Bahamas First Class Medical Certificate issued 09 August, 2010 with no 

limitations and no restrictions. The amount of hours flown by Mr. Storr in the last 24 hours, 7days, and 30 days 

prior to the accident, with the exception of the flight conducted to Marsh Harbour, Abaco on October 5, 2010, the 

same day, prior to the accident flight which accounted for approximately 2 hours, could not be verified as no duty 

log or records were made available to the investigation team. No records were made available to verify whether 

Mr. Storr had accomplished a required proficiency check (required of all pilots engaged in commercial air 

transportation) within the specified time frame stipulated by CASR Schedule 14.095, 14.120 or 14.180 for 

commercial operations.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 20

1.6 Aircraft Information

1.6.1 General

Aircraft C6-NLH a Bahamas registered Cessna 402C aircraft was manufactured in 1981 by Cessna Aircraft

Company and designated serial number 402C0458.

The aircraft was fitted with two (2)

reciprocating engines, model 

number TSIO 520 VB 

manufactured by Teledyne 

Continental Motors. The aircraft 

was listed in the normal category, 

standard classification. The aircraft 

was issued an Airworthiness

Certificate on May 19, 2010 by the 

Flight Standards Inspectorate, 

Nassau, Bahamas.

The accident airplane was 

configured with 10 seats, 2 pilot‟s seat, and eight (8) additional seats. Six of those eight passenger seats were 

single seats and 1 set of seats were a double seat which was positioned near the entrance door and was designated 

seats 7 and 8. The airplane had a main entry door which was located on the left side of the aircraft aft of the left 

wing and adjacent to seats 7 and 8, and two emergency exits one located forward and above the left wing, next to 

the pilot‟s seat (seat 1) and one at seat four (which was located behind the co-pilot‟s seat) on the right side of the 

aircraft, above the right wing.

The aircraft also had a cargo door on the left side aft of the left wing, which was joined to the main entry door and 

adjacent to seats 9 and 10 just forward of cargo area Bay A. The cabin cargo storage area began just aft of seats 9 

and 10 and was designated cargo areas Bay A and Bay B. Cargo areas were also located in each wing lockers aft 

of each respective engine nacelles. Additionally, cargo was also stored in the Nose Luggage and Avionics Bay 

area of the aircraft above the nose wheel storage compartment.

1.6.2 Aircraft Description

The Cessna 402C is a twin engine, all metal, low wing airplane with retractable tricycle landing gear. The 

fuselage is of semi-monocoque6construction: the wing, tailplane and fin are of conventional aluminum 

construction. The aircraft can be configured for either passenger or freight transport. In the passenger role, the two 

forward seats are pilot‟s seats. A maximum of eight (8) passenger seats may be installed aft of the pilot seats. 

Minimum flight crew required is one (1) pilot.

1.6.3 Engines

The Cessna 402C is powered by two Teledyne Continental Motors model TSIO-520-VB engines which are turbo 

charged, fuel injected, direct drive, air-cooled and horizontally opposed with six cylinders each with a 520 cubic 

inch displacement. It is rated at 325 horsepower at 2700 propeller rpm and 39.0 inches hg manifold pressure to 

the critical altitude of 12,000 feet. Each engine is provided with an oil pump, fuel pump, vacuum pump, propeller 

governor, tachometer generator, starter and alternator. 

 

6 Monocoque is a construction technique that supports structural load by using an object's exterior, as opposed to using an internal frame or

truss that is then covered with a non-load-bearing skin or coachwork.

Figure 3 C402C Seating diagram
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 21

1.6.4 Propellers

Propellers installed on the Left and Right engines of C6-NLH, were manufactured by McCauley Accessory 

Division Cessna Aircraft Company. The types of propellers were all metal, three-bladed, constant speed, full 

feathering, single acting, non-reversible, hydraulically actuated, governor regulated propellers. Each propeller 

utilizes oil pressure which opposes the force of springs and counterweights to obtain correct pitch for engine load. 

They were both part number 0850334-29 and had an operating limit of 2700 rpm maximum speed. 

Propeller Serial number 815478 was installed on the left engine and serial number 920620 was installed on the 

right engine of C6-NLH. The maintenance history and times accumulated on both propellers or date installed on 

each respective engine could not be determined. Permanent maintenance records were requested from the pilot‟s 

wife and other local personnel up to the publication of this final report, but none were provided.

The engine and propeller controls are conventional in that each engine is controlled by three levers [1. Throttle. 2. 

Propeller and; 3. Mixture], which are mounted on the control pedestal in pairs in the order 1, 2, and 3 from left to 

right. The Throttle control lever is used to increase or decrease the engine power by moving the butterfly valve 

in the fuel air control unit. The Propeller control lever is used to change the propeller pitch to maintain or set a 

desired engine rpm. The Mixture control lever is used to control the amount of fuel to be metered by the fuel-air 

control unit.

1.6.5 Flight Controls

The flight controls consists of the ailerons, elevators and rudder and their respective trim systems. All of these 

systems are constructed of aluminum and are statically balanced. 

Each aileron is attached to the rear main wing spar at two points. The aileron is actuated by a bellcrank which is 

attached to a wheel in the wing. The wheel is actuated by cables attached to the pilots control wheel. When the 

rudder is actuated, a spring assembly, interconnected to the aileron system, causes the ailerons to automatically 

assist the turn. Aileron trim is achieved by a trim tab attached to the left aileron with a full length piano type 

hinge. The trim tab is actuated by a push pull rod which is attached to a jack screw type actuator in the wing. The 

actuator is driven by cables attached to the trim control knob on the cockpit control pedestal. The aileron trim tab 

also acts as a servo tab so that aerodynamic forces on the tab will move the ailerons to the selected position, 

which reduces the forces required to activate the ailerons in flight

The rudder is attached to the vertical stabilizer rear main spar at three points. The rudder is actuated by a 

bellcrank attached to the bottom of the rudder. The bellcrank is actuated by cables attached to the cockpit rudder 

pedals. When the rudder is actuated, a cable and spring assembly that is connected to the aileron system causes 

the ailerons to automatically assist the turn. The rudder trim is achieved by a trim tab attached to the lower half 

of the rudder with a full length piano type hinge. The trim tab is actuated by a push-pull rod which is attached to 

a jack screw type actuator in the vertical stabilizer. The actuator is driven by cables attached to the rudder trim 

wheel on the cockpit control pedestal. The rudder trim tab also acts as a servo tab so that aerodynamic forces on 

the tab will move the rudder to the selected position, which reduces the forces required to activate the rudder in 

flight. 

The elevator control surfaces are connected by a torque tube. The resulting elevator assembly is attached to the 

rear spar of the horizontal stabilizer at six points. The elevator assembly is actuated by a push pull rod which is 

attached to a bellcrank in the empennage. The bellcrank is actuated by cables attached to the pilots control wheel.

Elevator trim is achieved by an elevator trim tab attached to the right elevator with a full length piano-type 

hinge. The trim tab is actuated by a push pull rod which is attached to a jack screw type actuator in the horizontal 

stabilizer. The actuator is driven by cables attached to the trim control wheel on the cockpit control pedestal.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 22

1.6.6 Aircraft Fuel System

The fuel system consists of two main tanks outboard of each engine, two fuel selector valves and emergency 

shutoff valves and necessary components to complete the system. The main fuel tanks are an integral portion of 

the sealed wet wing. These tanks supply their respective engine with fuel for normal operations including takeoffs and landings. 

An auxiliary fuel pump, located outside the tank, provides fuel pressure for priming during engine start. In the 

event of an engine fuel pump failure, the auxiliary fuel pump will supply fuel to the engine if the auxiliary fuel 

pump switches are on. 

There are two fuel selector valves controlling fuel supply to the engines. They are located in the wings and are 

operated by cables from selection knobs situated on the cockpit floor between the pilots' seats. Each valve has 

three selection positions; OFF, LEFT MAIN AND RIGHT MAIN. 

Normally each engine is fed from its own tank, i.e. left engine from left tank, but the valves allow an engine to be 

fed from the opposite tank. This is referred to as "cross-feed". The mechanical detents, which provide positive 

positioning of the valves in their three functioning positions, are built into the valves. The knobs in the cockpit 

can themselves move freely but they are constrained by the detents through the cable system. 

There is also an emergency shutoff control adjacent to and immediately behind the fuel selector controls. Its 

function is to isolate the fuel cross-feed lines from the fuel tanks in the event of fire or landing with the gear 

retracted. 

C6-NLH, a 402C aircraft was approved for 100 (formerly 100/130) Grade Aviation Fuel (Green) and as an 

alternate, 100LL Grade Aviation Fuel (Blue). It has a total fuel capacity of 213.4 (U.S. Gallons) and 204.0 Usable 

Fuel (U.S. Gallons).

1.6.7 Weight and Balance

Three (3) Bahamas certified AOC holders at the domestic section of Lynden Pindling Int‟l Airport stated that they 

were approached by one of the victims of the accident aircraft inquiring about the price and their availability to 

conduct a charter to San Salvador Bahamas. 

They (AOC) all confirmed they declined to conduct the charter because looking at the amount of luggage, 

equipment and size of person that wanted to travel, the combined weight exceeded the legal amount for the size 

aircraft that they operated ( Cessna 402C and Hawker Beechcraft B100). One operator offered a larger aircraft 

that was able to accommodate all of the equipment and persons present, but his offer was declined by the victim 

because the price was more than he was willing to pay.

Sometime thereafter, arrangements were made by the same individual for Acklins Blue Air Charter to fly the 

passengers and their equipment and luggage to San Salvador, Bahamas. 

The accident investigators could not determine if all of the equipment and luggage that the victims had with them, 

(that were presented to the previous 3 AOC holders) were placed on the accident aircraft. However, all of the 

persons with him were all victims of the airplane crash.

On October 5, 2010 at 8:45am, the aircraft was fueled adding 80 gallons of Avgas and 2 quarts of aviation oil 

were purchased from Executive Flight Support. On the same day at 12:06pm an additional 60 gallons of Avgas 

were purchased. No indication of how much fuel was on board the aircraft prior to the additional 60 gallons that 

was added. The pilot however listed his fuel endurance as 4 hours. 
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 23

Some luggage was recovered from the wreckage and accident site; however, no determination could be made 

whether this was the total luggage and equipment that was shown to the previous AOC holders. The aircraft‟s 

total weight at takeoff could not be accurately determined. The center of gravity also could not be accurately 

determined due to no eyewitnesses of the loading process of the aircraft. The investigation team was able to 

determine that the aircraft had exceeded the weight and balance limitation and center of gravity envelope for the 

Cessna 402C aircraft. Post accident calculations determined that the aircraft was over the maximum allowed 

weight for takeoff by more than 500 pounds. (See Weight and Balance Scenario 1.16.4)

1.6.8 Weighing Report

No documents could be obtained to verify whether the aircraft was weighed within the specified period as per 

BASR Schedule 5, as the aircraft permanent records were requested from the pilot‟s wife and other local 

personnel but they were never provided up to the publication of this report.

1.6.9 Limitations

Maximum Ramp Weight: 6,885 pounds

Maximum Take-off Weight: 6,850 pounds 

Maximum Landing Weight: 6,850 pounds

Maximum Zero Fuel Weight: 6,515 pounds

1.6.9.1 Operating Speeds

The following aircraft operating speeds, expressed in Knots Indicated Airspeed (KIAS) were relevant to the 

accident flight.

 Buffet onset speed (flaps UP at MTOW) 80

 Stalling Speed (power off flaps up) 80

 Minimum control speed (flaps UP) VMCA

7

 80

 One engine inoperative best rate of climb speed (VY)

8

 104

 One engine inoperative best angle of climb speed (VX) 109

 Blue Radial Line9 104

1.6.10 Maintenance History of the Aircraft

The permanent maintenance records were requested from the pilot‟s wife and other local personnel but none was 

provided. Therefore a history of the aircraft could not be determined. However, some major events such as 

engine overhauls, cylinder overhauls and repairs paperwork was obtain from the repair shop. Additional 

information pertaining to the manufacture of the cylinders was also obtained.

1.6.11 Maintenance History of the Left Engine and Propeller

Work orders provided by Airmotive Engineering Corp pertaining to work performed on the ECi parts was 

obtained, but is not a complete history. Extensive research was performed by the NTSB and is contained in the 

NTSB materials Laboratory factual report referred to in Appendix 5.1

 

7 This is the minimum flight speed at which the airplane is directionally controllable with one engine inoperative and with a 5 ̊ bank 

towards the operative engine.

8

This speed delivers the greatest gain in altitude in the shortest possible time with one engine inoperative at sea level, standard day 

conditions and 6,850 pounds weight.

9 One engine inoperative best rate-of-climb speed, at sea level, standard day condition and 6,850 pounds weight.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 24

1.6.12 Maintenance history of the Right Engine and Propeller

The permanent maintenance records were requested from the pilot‟s wife and other local personnel but none was 

provided. Therefore a history of the right engine and propeller could not be determined.

1.7 Meteorological Information

Weather observations are transmitted in coordinated universal time / Zulu time (UTC / Z). Eastern Daylight Time 

is 4 hours behind UTC / Z time. Bahamas Meteorological Department at the Lynden Pindling International 

Airport issued the Bahamas Area Forecast10 which originated at 1630 UTC; dated Tuesday October 5, 2010 valid 

for 12 hours from 1800 UTC reported a combination stationary front along with a surface trough across the 

northwestern and central Bahamas producing unstable weather through the forecasted period. Significant 

Weather section of the Bahamas Area Forecast over the central and northwest Bahamas indicated scattered to 

broken clouds from 1,200 feet to 1,800 feet with towering cumulus11 and cumulonimbus12 clouds. A scattered and 

broken layer of clouds were at 3,000 feet and 5,000 feet respectively. 

A layered broken to overcast clouds were 8,000 feet and 12,000 feet up to 24,000 feet (FL240)13. Widespread rain 

was forecasted with scattered showers and thundershowers mainly in the vicinity of the trough or front in lines 

and clusters with towering cumulus or cumulonimbus with tops above FL180 to FL240. Ceiling14 and / or 

visibility was reduced below 1,200 feet and 3 nautical miles in heavy showers, rain and thundershowers. 

Moderate to severe turbulence in the vicinity of all towering cumulus and cumulonimbus clouds was forecasted.

Forecasted Upper Winds and Temperature for the same time period from 1800 UTC at the 2,000 foot level in the 

northwestern Bahamas were winds 030 ̊ at 28 knots, visibility unrestricted scattered clouds at 1,800 feet, scattered 

clouds at 12,000 feet, broken cloud layer at 3,500 feet, another broken layer at 10,000 feet. From the 06 October 

at 1200 Z expect the winds to be from 030 ̊ at 24 knots, visibility unrestricted, scattered clouds from 1,600 feet 

and a broken layer at 24,000 feet.

Aerodrome Forecasts for Lynden Pindling Int‟l Airport (MYNN) indicated on the 05 October from 1600Z to the 

05 October 1800Z to the 06 October at 1800Z winds from 090 ̊ at 06 kts. The 1600Z METAR15 (12:00pm local 

time) indicated that the winds were 100 degrees at 6 knots; visibility was 7 nautical miles in light rain showers. 

Clouds were scattered at 1,800 feet, and broken at 10,000 feet and then again broken at 24,000 feet. The 

temperature was 88 ̊F16 / 31 ̊ C17, and the dewpoint18 was 81 ̊F / 27 ̊C. The barometric pressure19 was 1012.2 

HPA20 and altimeter 29.89” HG.21

 

10 Area Forecast - An Aviation Area Forecast or FA encompasses the weather conditions over a large regional area and is considered one 

of the better sources of information for en route weather. It is also beneficial in verifying airport conditions at airports that do not have 

terminal aerodrome forecasts.

11 Towering Cumulus Clouds - Cumulus clouds are a type of cloud with noticeable vertical development and clearly defined edges. 

Cumulus means "heap" or "pile" in Latin. They are often described as "puffy" or "cotton-like" in appearance.

12 Cumulonimbus Clouds - Cumulonimbus (Cb) is a type of cloud that is tall, dense, and involved in thunderstorms and other intense 

weather

13 FL - A Flight Level (FL) is a standard nominal altitude of an aircraft, in hundreds of feet. This altitude is calculated from the 

International standard pressure datum of 1013.25 hPa (29.92 inHg), the average sea-level pressure, and therefore is not necessarily the 

same as the aircraft's true altitude either above mean sea level or above ground level.

14 Ceiling - With respect to weather conditions, a ceiling refers to the height of the lowest obscuring cloud layer above the ground.

15 METAR - METAR is a format for reporting weather information.

16  ̊F / Fahrenheit - Fahrenheit is the temperature scale proposed in 1724 by, and named after, the physicist Daniel Gabriel Fahrenheit

(1686–1736).
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Final Report C6-NLH Page 25

1.8 Aids to Navigation

No discrepancies with navigational aids were known or reported.

1.9 Communications 

No difficulties with internal or external communications were known or reported.

1.10 Aerodrome Information

Lynden Pindling International Airport (IATA: NAS, ICAO: MYNN), formerly known as Nassau 

International Airport, is the largest airport in The Bahamas, and the largest international gateway into the 

country. It has an airport elevation of 16 feet above mean sea level. The coordinates are 25 ̊ 02‟20” N and 077 ̊ 

27‟58”W. It is a major hub for Bahamasair and is located in the western district of New Providence Island near 

the capital city of Nassau. Due to a large amount of flights to the United States, the airport contains U.S. Border 

preclearance facilities allowing all US flights to operate as domestic flights upon arrival at their destination.

The name of the airport was officially changed on July 6, 2006 in honor of The Right Honorable Sir Lynden 

Oscar Pindling (22 March 1930 – 25 August 2000), first Prime Minister of The Commonwealth of the Bahamas.

The airport is served by runways 14/32 which is oriented southeast and northwest and runway 09/27 which is 

oriented east and west. Runway 14/32 is 11,353 feet long and 150 feet wide and runway 09/27 is 8,273 feet long 

and 150 feet wide, both are paved surfaces and constructed of asphalt. (See Appendix 5.15 Aerodrome Chart)

1.10.1 Nassau Airport Development Company (NAD)

Nassau Development Company Limited was incorporated on June 6, 2006 under the provision of the Companies 

Act 1992. The company is a wholly-owned subsidiary of The Airport Authority. The registered office and 

principal place of business is located at the Lynden Pindling International Airport, Nassau, Bahamas.

The principal functions of NAD are to manage, develop and maintain MYNN and to transform the airport into a 

premier world class facility in a most efficient and commercial manner. NAD commenced its operations on 

October 1, 2006. On October 19, 2006, NAD entered a 10 year Management Agreement with YVR Airport 

Services Ltd. (YVRAS), to manage, operate and maintain MYNN and to place certain executives within NAD.

On April 1, 2007 NAD entered a 30-year Lease Agreement with the Airport Authority. In accordance with this 

Lease Agreement, NAD is responsible to manage, maintain and operate MYNN and rent is paid to the Airport 

Authority.

 

17  ̊C / Celcius - Celsius (known until 1948 as centigrade) is a temperature scale that is named after the Swedish astronomer Anders 

Celsius (1701–1744).

18 Dewpoint - The dew point is the temperature at which a given parcel of humid air must be cooled, at constant barometric pressure, for 

water vapor to condense into water.

19 Barometric pressure - Atmospheric pressure is the force per unit area exerted against a surface by the weight of air above that surface in 

the Earth's atmosphere.

20 HPA - Hectopascal (hPa), a unit of pressure equivalent to about 1/1000 of 1 atmosphere.

21 HG - Hg may refer to: Mercury (element) or Hg 
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Final Report C6-NLH Page 26

1.10.2 Aircraft Rescue and Firefighting

The Airport Authority at Lynden Pindling International Airport (MYNN) maintains a level 7 ARFF22 facility on 

the airfield for all alerts on airport property. The station is owned and operated by the Airport Authority. It is 

continuously staffed (24 hours) with a minimum of nine (9) firefighters. ARFF has an airport emergency plan 

detailing response, recovery and resolution actions in the event of an accident or incident involving aircraft at the 

airport or within the boundary of MYNN.

The station houses four (4) crash trucks, three (3) Oshkosh T1500 trucks with a capacity of 1500 gallons of water 

and 200 gallons of foam concentrate and one (1) Ford 550 truck with a capacity of 300 gallons of water and 20 

gallons foam concentrate. Both trucks have a capacity of 400 pounds of dry chemical. ARFF personnel receive 

approximately 6 months of training initially and a minimum of 150 hours annually. This training is done in 

phases quarterly. This refresher training is done in South Carolina in the United States of America. The training 

(initial and recurrent) includes but is not limited to, hot fire drills, pressure fed fuel fires, rescue simulation and 

apparatus operation. The training includes practical, classroom and computer based scenarios.

1.10.3 Air Traffic Control

The ATCT at MYNN is CAD-staffed combined terminal approach radar control (TRACON)23 and tower with 

about 180,000 operations per year. The tower cab is continuously open and is located north of runway 09/27, and 

southwest of runway 14/32 centered between runways 09/27 and 14/32. Air traffic control (ATC) radar data are 

provided by an Airport Surveillance Radar “ASR-8” Approach Radar System, with “ARTS 2A” Automation 

Software. The radar antennae head is located approximately 1 nm south of the Control Tower.

C6-NLH was handled by three (3) air traffic controllers on the day of the accident: the clearance delivery 

controller, the ground controller and the tower controller, all were classified as Grade One Air Traffic Control 

Officers. The ground controller notified ARFF as well as the Princess Margaret Hospital of the accident.

1.11 Flight Recorders

C6-NLH was not fitted with a flight recorder as none was required by regulations for this type of aircraft.

1.12 Wreckage and Impact Info

1.12.1 General Wreckage Description

The airplane sustain substantial damage to the entire upper fuselage from the windshield aft to Bay A luggage 

compartment, left and right engines, left and right wings, nose landing gear, nose luggage compartment and right 

and left elevator and horizontal stabilizer. Other damages include damages done as a result of being submerged in 

salt water of the lake. The wreckage path and instrument evidenced that the airplane was on a magnetic heading of 

approximately 220 degrees. The aircraft was not equipped with a cockpit voice recorder; therefore no information 

was available of what conversation, if any, took place between the crew, during the last few moments in the 

cockpit.

 

22 ARFF- Aircraft Rescue and Firefighting (ARFF) is a special category of firefighting that involves the response, hazard mitigation, 

evacuation and possible rescue of passengers and crew of an aircraft involved in (typically) an airport ground emergency.

23 TRACON - A Terminal Radar Approach Control (or TRACON) is an air traffic control facility usually located within the vicinity of 

a large airport. Typically, the TRACON controls aircraft within a 30-50 nautical mile (56 to 93 km) radius of the airport between the 

surface and 10,000 to 15,000 feet (4,600 m). A TRACON is sometimes called Approach Control or Departure Control in radio 

transmissions.
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Final Report C6-NLH Page 27

The airplane‟s main wreckage was located about 400 yards from shore in about 3 to 5 feet of water at high tide. It 

was approximately 1⁄4 of a mile from the approach end of runway 27. It was submerged and came to rest oriented 

on an approximate magnetic heading of 220 degrees (about 60 ̊ from the westerly inbound course for runway 27).

The recoverable parts of the aircraft were located within the immediate area of the wreckage. 

First contact with the water was made with the nose of the aircraft in a left nose down, inverted position at a high 

rate of speed followed by a cart wheeling motion where the right wing and right elevator made next contact 

(based on evidence post accident). The left wing tank exhibited a type of bulging deformation which showed that 

it had contained a large amount of fuel at impact. 

No fuel remained when the aircraft was recovered and examined. Both left and right wing fuel tanks were 

ruptured during the crash sequence which allowed all fuel in them to escape into the lake. Though all of the fuel 

from both left and right wing tanks had escaped during or after the crash, it had not ignited and the aircraft had not 

been affected by fire. Fragmented airplane wreckage was found surrounding the crash site. 

A complete survey of the accident scene and aircraft structure was accomplished; however, the severity of the 

damage precluded a complete accounting of all the aircraft structure. From this ground evidence and the crushing 

damage to the fuselage, cockpit, instrument panel and right wing, it was assessed that at first impact the aircraft 

was at a steep bank with an angle in excess of 45 degrees as reported by eyewitnesses. No objective indications 

were obtained to quantify the speed at impact or the rate of descent. 

The alternator switch for the right engine was found in the "OFF" position during post accident documentation. It 

was one of the many switches for the right engine that was found in the “OFF” position. Engine Serial number 

248270 was installed on the left wing of C6-NLH and serial number 290209 was installed on the right wing of 

C6-NLH. Post accident investigation revealed damage of #2 cylinder of the left engine consistent with the 

cylinder having experienced a mechanical failure.

The engine controls, throttle, propeller and mixture were all found in the full forward position which was 

inconsistent with the engine securing checklist. However, other steps in the engine securing checklist pertaining to 

the right engine were accomplished (Step 11) such as Magneto, Alternator, Battery, Auxiliary fuel pump switches, 

and both Fuel selector valve knobs, all were found in the "OFF" position, which confirms that the right engine 

may have been intentionally or inadvertently secured without accomplishing the first steps (Step 5) in the 

checklist such as retarding throttle, feathering propeller and shutting off fuel (mixture control) on the affected 

engine that was going to be secured. (See Appendix 5.10 Engine Failure after Take-off checklist).

The aircraft was not found to be structurally complete post impact with all its flying controls and control surfaces 

normally attached. Its landing gear was extended and the gear selector handle was in the down and lock position. 

The flaps were retracted. Rudder, elevator and aileron trim tabs position could not be verified as the control wheel 

column, where they were attached, had been destroyed by impact forces. 

The engine control pedestal had been partially dislodged and the control levers (throttles, propeller and mixture) 

were found in line near the full forward position range of movement with the exception of the left throttle which 

was found slightly aft of the full forward range of movement. The feathering detents were intact and showed no 

gross damage.

Both left and right fuel selector knobs were discovered in the "OFF" position which may have been selected by 

the pilot intentionally or inadvertently during the engine securing sequence or it may be possible that one or both 

could have been moved by the accident sequence.
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Final Report C6-NLH Page 28

1.12.2 Fuselage

Examination on site revealed that the windshield, roof and both 

left and right walls of the fuselage had disappeared and was 

folded rearward to the main entry / cargo door but was still 

attached at the point just beyond Seats 9 and 10 and above Bay 

Area A. The nose of the airplane was crushed rearward to the left.

The fuselage structure above the wing center section including 

both emergency exits and surrounding structures were distorted 

and impact damaged. The aft fuselage, just forward of the 

empennage was still attached but exhibited severe impact 

damage.

The fuselage lower structure including the floor remained intact 

but was damaged and separated during recovery. All cables, 

rudder, elevator and ailerons were accounted for in the wreckage.

1.12.3 Engines and Propeller

Both engines were Teledyne Continental Motors TSIO-520-VB. The left engine and propeller remained attached 

to the left wing which was still attached to the fuselage. The right engine minus its propeller was still attached to 

the portion of the right wing that remained post accident. Preliminary inspection of both engines revealed no 

evidence of pre-impact malfunction. Inspection however of the No. 2 cylinder of the left engine revealed a 

mechanical failure of that cylinder. Both engines exhibited damages consistent with post accident recovery 

efforts. The engine control pedestal received extensive damage. All control levers (throttle, propeller and mixture) 

were found in the full forward position. However, explanations of why all engine control levers were full forward, 

yet engine control switches for the right engine were found in the “OFF” position is not readily apparent. It is 

inconsistent with engine securing procedures in the Cessna Information Manual. All engine control levers were 

found bent to the right which further coincides with the crash sequence which was left to right as described by 

eyewitness statements. The control wheel for the elevator, rudder and aileron trim tabs was destroyed in the crash.

The right propeller was separated from the right engine. This may have occurred during the initial impact or 

subsequent post impact sequence. It however, was never recovered. The left propeller however, was still found 

attached to the left engine. The propeller hub received substantial damage but was still found attached to the left 

propeller. All blades for the propeller were found still attached to the propeller hub. Evidence showed that the left 

propeller blades were not feathered. Eyewitness reports states that the engine continued to run approximately 10 

seconds after water impact. The blade damage appears to be consistent with the propeller not being feathered and 

would account for the rotational damages found on the left propeller which would indicate that the left propeller 

may have been rotating at impact

1.12.4 Wings

Pieces of the right wing outboard of the right engine nacelle, including right wing leading edge, trailing edge, 

flaps, wing tip, aileron and strobe light had separated and were not recovered from the lake. What remained 

including the right wing spar was severely fragmented with pieces located throughout the wreckage path. The left 

wing with engine and propeller still attached, remained attached to the fuselage and exhibited a type of bulging 

deformation and localized impact damages along its entire length. All fuel contained in both wing tanks escaped. 

Though the fuel in the left and right wing had escaped during or after the crash, it had not ignited and the left nor 

right wing and engines had been affected by fire. The right wing sustained substantially more damage than the left 

wing.

Figure 4 Fuselage post accident
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Final Report C6-NLH Page 29

Both left and right landing gear were found in the down and locked position. The gear selector handle on the 

instrument panel confirmed that the gear was indeed selected to the down position. No impact damages were 

noted to the left and right main landing gears. The nose landing gear was separated from the fuselage possibly 

during the initial impact where the nose section of the airplane seemed to have received the brunt force of the 

impact. The impact damage to the airplane precluded the determination of flight control continuity. However, the 

examination of the wreckage revealed no evidence of flight control or other system malfunction before the aircraft 

impacted the water. Further, there was no evidence of in-flight or pre-impact fire. There were no indications of 

separation of parts before initial impact. The wreckage evidence indicated that both flaps were in the retracted 

position at the time of the impact. Both engines were examined during the field investigation. Neither showed 

evidence of fire damage.

 

1.12.5 Empennage and Flight Controls

The left aileron of C6-NLH received substantial damage in the accident. The entire right wing leading edge 

(9'10"), outboard of the right engine nacelle, as well as approximately 7'9" of the trailing edge of the right wing, 

outboard of the right engine nacelle and right flaps were destroyed. The right aileron was destroyed with the 

leading and trailing edge of the right wing. Approximately 4'8" of the trailing edge of the right wing, outboard of 

the rear right engine nacelle with wing flaps still attached was recovered. The missing wing and damages 

sustained to the forward attachment point and leading edge right wing outboard of the right engine nacelle is 

consistent with eyewitness reports of the aircraft going inverted, nose down and cart wheeling to the right after 

impact. (See Appendix 5.11 Crash aircraft diagram and Appendix 5.12 Reference aircraft diagram)

The aileron trim tab on the left aileron of C6-NLH sustained substantial damage. Additionally, the trim control 

knob on the cockpit control pedestal was destroyed during the crash sequence. (See Appendix 5.11 Crash aircraft 

diagram and Appendix 5.12 Reference aircraft diagram).

The vertical stabilizer, rudder and rudder trim tab remained attached to each other and the fuselage; these surfaces 

exhibited no evidence of direct impact damage however, minor damage was noted. The left horizontal stabilizer 

and elevator remained attached to each other and the vertical stabilizer. They exhibited some impact damage. The 

right horizontal stabilizer, portion of the elevator and the elevator trim tab remained attached to each other and to 

the vertical fin. They exhibited evidence of severe impact damage. The rudder of C6-NLH received minor 

damages however, the rudder pedals in the cockpit received substantial damages. The rudder trim tab of C6-NLH 

received minor damages. All cables were accounted for and had to be cut by investigators during the recovery 

effort. The control wheel located on the cockpit control pedestal was destroyed during the crash sequence. The 

lack of damage to the rudder and vertical stabilized is consistent with the nose down crash sequence eyewitnesses

described.

The right horizontal stabilizer and right elevator were bent in an upward angle approximately 30 to 40 degrees. 

When compared to a reference 402C, it was noted that the outboard right horizontal stabilizer and the outboard 

right elevator were missing approximately 4'5" and a portion of the right elevator trim tab was also missing which 

is consistent with the aircraft going inverted and hitting nose first and cart wheeling to the right. The outboard 

portion of the right elevator (approximately 2.5 feet) was separated from the main wreckage and never recovered 

from the lake. The outboard portion of the right horizontal stabilizer was bent upward at about a 30 to 40 degree 

angle. (See Appendix 5.11 Crash aircraft diagram and Appendix 5.12 Reference aircraft diagram) The control 

wheel pedestal was destroyed in the accident sequence. All cables were accounted for and were cut by 

investigators during recovery and initial investigation to access other components during documentation.

1.12.6 Damage to Seats and Cabin Floor

The structural damage to the cabin and seats was assessed both at the accident site and after removal of the 

aircraft wreckage to the hanger. In some cases the complete lower seat frame had detached from the floor 
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Final Report C6-NLH Page 30

attachments and in one case there had been separations within the seat structure, leaving parts of the lower seat 

frame attached to the cabin seat tracks. The lap straps and attachments had remained intact, retaining the 

occupants in their seats. The seats and its occupants had been ejected during the crash sequence. Two seats were 

never recovered and possibly lost in the lake. All seat belts of seats found were accounted for. As all passengers 

were ejected, no accurate indication of where each person sat in the aircraft could be established.

There was considerable evidence, in the frames and stringers of the lower cabin structure, that the cabin floor had 

been subjected to high vertical and longitudinal impact loads: the result had been rotation of the lower fuselage as 

the cabin floor moved forward and downward. The only passenger seat that remained attached to the cabin floor 

was seat number 9, which it is assumed was either not occupied or if occupied, its occupant was not wearing the 

seat belt. It could not be positively determined what proportion of the damage to the seating had occurred in the 

first impact with the water and what had occurred due to the cart wheeling of the aircraft after initial impact.

1.12.7 Fuel Selection

Both fuel selector valves were found in the “OFF” position. The fuselage structure below the floor had been 

crushed and distorted in the crash. This was the area of the fuselage‟s first impact with the ground and it is likely, 

therefore, that the cables to the selector valves may have been trapped and moved at first impact. 

The possibility that the cable was moved prior to, or during the impact, before being trapped in the “OFF” 

position cannot be discounted.

1.12.8 Left Console Panel

The left console panel represented here depicts the labels for 

switches and the picture that follows shows the actual position 

that those switches were found. Only affected switches that

illustrate actions done with reference to the right engine which 

were intentionally or inadvertently secured, will be labeled here,

see left and right side console panel for labels of other switches

of interest.

Switches # 5 left to right (3), which represents Left Alternator, 

Battery and Right Alternator.

Switches #7 left to right (2), which represents Left and Right 

Auxiliary Fuel (boost) pumps.

Switches #8 left to right (4), which represents Left and Right 

Magneto Switches for the Left Engine (2) and Left and Right 

Magneto Switches for the right engine (2).

Figure 5 Left Console
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 31

On the console panel located on the left fuselage wall just below 

the emergency exit, next to seat number 1, the investigation team 

discovered that both left and right magneto switches for the right 

engine were found in the "OFF" position, (switches #8) see 

system description figure 7.

The battery and right alternator switch (switches #5) for the right 

engine was also discovered in the "OFF" position see system 

description figure 7.

Auxiliary fuel pump for the right engine (switch #7) also found 

in the "OFF" position see system description figure 7.

The left and right magneto switches for the left engine as well as 

the left alternator switch for the left engine were found still in the 

“ON” position. 

Both fuel selector valve knobs located on the floor 

between the left and right pilot's seat were found in 

the "OFF" position.

It could not be confirmed whether the knobs were 

selected by the pilot intentionally or whether they 

were moved as a result of the accident sequence.

Right throttle lever, left and right propeller lever as 

well as left and right mixture control levers were all 

found in the full forward position with the exception 

of the left throttle lever which was found slightly aft 

of the full forward position, (which represents full 

power on that engine).

Figure 6 Actual console Panel for C6-NLH

Figure 7 Fuel Selector Valves Left and Right Engine

Figure 8 Power Quadrant
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Final Report C6-NLH Page 32

1.13 Medical and Pathological 

The body of the pilot and seven (7) victims were recovered the day of the accident; one person (identity unknown)

was found still alive. He sustained serious injuries and was transported to the Princess Margaret Hospital. He was 

examined by Emergency Medical Technicians on the Ambulance; however, he succumbed to his injuries enroute. 

The pilot and the remaining six (6) victims were transported to the Rand Laboratory (Morgue) located at the 

Princess Margaret Hospital. On the third day after the accident, the body of the 9th victim was recovered from the 

lake where the accident occurred. Post-mortem examinations were performed by pathologist of the Rand 

Mortuary at the Princess Margaret Hospital, Nassau Bahamas on all occupants of the aircraft. The causes of death 

of all occupants were determined to be multiple blunt force injuries due to airplane crash. 

Specimens of liver, blood, stomach contents, urine and vitreous humor of listed pilot in command on record Mr. 

Nelson Hanna were obtained by pathologist from the Department of Pathology at the Princess Margaret Hospital. 

The diagnostic specimen for toxicology was sent via DHL Express, in a Federal Aviation Administration ToxBox Kit to the Bio-aeronautical Sciences Research Laboratory at the Civil Aerospace Medical Institute (CAMI) at 

the Federal Aviation Administration Mike Monroney Aeronautical Center (MMAC) 6500 South MacArthur 

Boulevard, Oklahoma City, Oklahoma 73169 for toxicological analysis. The analysis was to determine if there 

were any pre-existing disease, alcohol, drugs or any toxic substance in the pilot, which may have caused or 

contributed to the cause of the accident. Forensic Toxicology Report received from CAMI indicated no carbon 

monoxide, and no cyanide was detected in the blood. No ethanol was detected in the vitreous humor. Salicylate24

was detected in the urine. It was not determined if the amount found in his system was sufficient to impair his 

judgment to operate the aircraft.

1.14 Fire

Examination of the wreckage concluded no fire was involved pre or post crash.

1.15 Survival Aspects

1.15.1 First Aid

Several persons driving along the perimeter road (Coral Harbour Road) of MYNN witnessed the crash and alerted 

authorities. Some of the passersby waded into the lake and proceeded to pull victims toward the shore. Search 

and Rescue facilities coordinators from Lynden Pindling International Airport, the Royal Bahamas Police Force 

(RBPF), the Royal Bahamas Defense Force (RBDF), National Emergency Management Agency (NEMA), and 

Nassau Airport Development Company (NAD) were notified of the accident immediately. The RBDF and RBPF 

were mobilized to Lake Killarney where the accident occurred. RBDF teams arrived with water rescue equipment 

and additional personnel about 20 minutes post accident. 

The characteristics and magnitude of the impact and subsequent destruction of the airplane indicated that the 

accident was non survivable. The impact forces exceeded human tolerances and no occupyable space remained 

intact. All occupied seats were detached from the floor tracks. The pilot and all passengers were ejected from the 

aircraft; all but two passengers was found still strapped in their seats. One passenger initially survived the crash. 

Having sustained serious injuries, he later succumbed to those injuries enroute to the Princess Margaret Hospital.

Postmortem examination of the occupants indicated that the characteristics of the fatal injuries sustained varied 

 

24 Salicylate - is an over the counter analgesic used in the treatment of mild pain. Any of several widely prescribed drugs derived from 

salicylic acid. Salicylates exert analgesic, antipyretic, and anti inflammatory actions. The most important is acetylsalicylic acid, or aspirin. 

Sodium salicylate also has been used systemically, and it exerts similar effects. Many of the actions of aspirin appear to result from its

ability to inhibit cyclooxygenase, a rate-limiting enzyme in prostaglandin biosynthesis. Aspirin is used in a wide variety of conditions, and, 

in the usual analgesic dosage, it causes only mild adverse effects. Severe occult GI bleeding or gastric ulcers may occur with frequent use. 

Large doses taken over a long period can cause significant impairment of hemostasis. 
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 33

according to the location of the persons in the crashed airplane. All of the injuries were consistent with 

deceleration trauma of different intensity consistent with the aircraft‟s impact and breakdown pattern.

1.15.2 Fire Service and Emergency Response

According to ATC control log aircraft C6-NLH was cleared for take-off at 1635UTC* (12:35 local). At 

1636UTC* tower controller advised C6-NLH that he “needed him to return” as “white smoke was trailing behind

his left engine.” The pilot attempted to return and land on runway 27 and crashed in the lake. Nassau Airport 

Authority Aircraft Rescue and Firefighting (ARFF) vehicles and personnel, located approximately 1 mile away 

from the crash site, responded immediately after one rescue personnel on duty having visually observed the 

accident and simultaneously receiving an alarm from Nassau control tower personnel. About 3 - 4 minutes after 

the crash, two (2) ARFF trucks, both fire suppression vehicles (a water equipped fire truck) approximately 10 

crash and rescue personnel and the chief fire officer arrived on scene. Other rescue personnel from the 

community, pilots from the general aviation center and passersby stopped to render assistance a few minutes later.

The first four bodies were recovered at approximately 1704 UTC (1:04pm local) approximately 30 minutes after

the crash by crash and rescue personnel as well as bystanders and pilots from the General Aviation Center. 

Approximately 1724 UTC, NAD was advised that a total of eight (8) bodies were recovered from the waters and 

brought to the shore.

Approximately 30 minutes after the crash additional assistance was provided by approximately 30 to 50 persons 

from the Royal Bahamas Defense Force. In all, more than 100 emergency response personnel were involved.

The aircraft wreckage site was declared a “biohazard” area, and access to the site was restricted to essential 

personnel only. The monitoring of the site and access control was provided by the Royal Bahamas Police Force. 

The site was guarded from the time of the accident until the final removal of the wreckage to the secure aircraft 

hangar at MYNN. The procedures imposed for working in this type of environment required the AAIPU 

investigative team, including party members, to wear personal protective gear and or take special safety 

precautions while working on site and during post recovery teardown and analysis. Flight plan form filed by the 

pilot or his agent, listed one (1) person on board. There was mass confusion about a ninth (9th) person that may 

have been on board the aircraft. Additional searches were conducted of the area of the crash on the second day 

during wreckage recovery and on the third (3rd) day after the accident, the 9th occupant of the aircraft was found in 

the marshes of the lake. 

The following notification timeline was prepared by ATC. 

*At 1635 UTC NAD was notified.

At 1637 UTC PMH was notified.

At 1639 UTC Mr. Hubert Adderley – Manager of Flight Standards Inspectorate was notified.

At 1640 UTC Captain Patrick Rolle Director of Civil Aviation Department was notified.

At 1650 UTC Mr. Joseph Albury Deputy Director ATC was notified.

At 1655 UTC Mr. Delvin R. Major IIC was notified by the Manager of FSI.

NAD EOC running log records indicate;

*At 12:33 hrs (1633UTC) ATC officer manning Clearance Delivery notified NAD about the accident

*At 12:35 hrs (1635 UTC) EOC was activated by EOC personnel.

*Additionally, CAD Daily Air Traffic Record lists the aircraft crash at 1633UTC / 12:33pm local.

*Discrepancies noted in the above timelines as transcript from ATC Tower controller transcript records 

aircraft departed at 1636UTC / 12:36pm local. However, Tower daily record of facility operation 

documents time of crash at 1633 UTC / 12:33pm local. (See Appendix 5.6 ATC Tower Transcript)
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Final Report C6-NLH Page 34

1.16 Tests and Research

Follow up examinations and testing was conducted regarding aircraft systems, operations procedures and human 

performance. Cylinder Analysis conducted in the United States at the NTSB Metallurgy Lab in Washington DC 

and Engine (Left and Right) were analyzed at Teledyne Continental Motors (TCM) Factory in Alabama. Reports 

attached in Appendix 5.1 and Appendix 5.2.

1.16.1 #2 Cylinder Analysis:

Examination of the No. 2 cylinder from the left engine was performed at the NTSB Materials Laboratory, located 

in Washington, DC. 

1.16.2 Left Engine Analysis

The left engines were examined at the manufacturer‟s facility with Bahamas oversight. See Appendix 2 Left 

Engine Factual Report TCM

1.16.3 Right Engine Analysis

The right engines were examined at the manufacturer‟s facility with Bahamas oversight. See Appendix 2 Right 

Engine Factual Report TCM.

1.16.4 Human Factors Research and Analysis

Research by noted authors Klein, G., (1993) Naturalistic Decision Making: Implications for Design. Wright-Patterson Air Force 

base, Ohio Crew System Ergonomics Information Analysis Center, Klein, G., (1993) A recognition primed decision (RPD) model of rapid 

decision making. In Klein, G., A., Orasanu, J., Calderwood, R., and Zsambok, C.E., (Eds), Decision Making in action: Models and 

Methods. Norwood, New Jersey, Ablex, p. 146, Wickens, C. D., (1984) Engineering Psychology and Human Performance. Columbus 

Ohio: Charles E. Merrill, p. 97 has concluded that human factors and the pilots action once a decision was made, played 

an important role in this accident. The full context of this research as applicable to this accident is contained in 

Analysis section 2.11.2 the pilots decision to return.

1.16.5 Weight and Balance Scenarios 

Weight and balance scenarios are as follows;

 The amount of fuel in the aircraft before the additional 60 gallons were added is unknown. However, pilot 

listed fuel on board as 4 hours duration. At a rate of 16.5 gal per hour, per side, for 4 hours duration, the 

aircraft would require a total of 132 gallons of fuel. 132 gallons of fuel calculated at a weight of 6 pounds per 

gallon, the weight of fuel on board was 792 pounds.

o 16.5 gal per engine, per hour x 2 engine = 33 gallon per hour total

o 33 gallon per hour x 4 hours = 132 gallons of fuel on board the aircraft

o 132 gallons of fuel x 6 pounds per gallon = 792 pounds of fuel

The empty weight of the aircraft was approximately 4,100 pounds. The maximum takeoff weight of the aircraft is 

6,850 pounds with a maximum total payload of 2,750 pounds. Payload weight was the aggregated weight of the

pilots, their bags, equipment, the passengers and their baggage and the fuel weight.

Approximately one month after the accident the baggage and equipment recovered were weighed. The recovered 

luggage and other items had a total weight of 282 pounds. The fuel load was 792 pounds based on above 

estimates and pilots report of 4 hour endurance. None of the passengers were weighed immediately before the 

flight. However, the pathologist measured the weight of each deceased person. The total for the 9 deceased 

occupants was 2,199 pounds.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 35

Weights listed below were retrieved from the coroner following examination of victims, it in no way indicates or 

suggests the seated position occupied by each occupant in the aircraft;

 Victim #1 NLH weight 15425 164*26

 Victim #2 NDS weight 280 245**27

 Victim #3 CLF weight 340

 Victim #4 CNW weight 375

 Victim #5 CM weight 230

 Victim #6 LC weight 130

 Victim #7 DRCT weight 190

 Victim #8 CLJ weight 320

 Victim #9 JL weight 180

Total 2199

o Passenger Weight 2,199# + (weight provided by coroner)

o Fuel Weight 792# +

o Baggage Weight 282# (weight of luggage that was recovered)

o Payload 3,273# + (max wt allowed is 2,750 pound)

o Empty weight 4,100# = (weight minus pax, fuel, luggage)

Total recovered weight on aircraft 7,373#

Total recovered weight on aircraft 7373# -

o Max wt allowed for T/O 6,850# = (Maximum Gross Weight)

o Amount overweight 523#

Center of gravity could not be determined as the seat each person occupied in the aircraft is unknown, and the 

amount of baggage and what compartment it was placed on the aircraft is unknown. As per the center of gravity 

graph and envelope, once weight and balance are within limits a plotted area should fall within the designated fore 

and aft limits of the envelope up to the maximum weight limit.

The center-of-gravity (CG) is the point at 

which an aircraft would balance if it were 

possible to suspend it at that point. It is the 

mass center of the aircraft, or the theoretical 

point at which the entire weight of the 

aircraft is assumed to be concentrated.

Its distance from the reference datum is 

determined by dividing the total moment by 

the total weight of the aircraft. The center-ofgravity point affects the stability of the 

aircraft. To ensure the aircraft is safe to fly, 

the center-of-gravity must fall within 

specified limits established by the 

manufacturer.

Figure 9 illustrates the center of gravity chart 

established by Cessna Aircraft Company for 

the Cessna 402C aircraft. When the weight of 

 

25

 Weights provided by Pathologist

26 * Pilot weight obtained from pilot last medical certificate issued 07 September, 2010

27 **Co-pilot weight obtained from co-pilot last medical issued 11 August, 2010

Figure 9 Center of Gravity Graph / Envelope
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 36

the aircraft is at or below the allowable limit(s) for its configuration (parked, ground movement, take-off, landing, 

etc.) and its center of gravity is within the allowable range, and both will remain so for the duration of the flight, 

the aircraft is said to be within weight and balance.

Incorrect weight and balance in fixed-wing aircraft

When the center of gravity or weight of an aircraft is outside the acceptable range, the aircraft may not be able to 

sustain flight, or it may be impossible to maintain the aircraft in level flight in some or all circumstances. Placing 

the CG or weight of an aircraft outside the allowed range can lead to an unavoidable crash of the aircraft.

Center of gravity out of range

When the fore-aft center of gravity is out of range, the aircraft may pitch uncontrollably down or up, and this 

tendency may exceed the control authority available to the pilot, causing a loss of control. The excessive pitch 

may be apparent in all phases of flight, or only during certain phases, such as take-off or descent. Because the 

burning of fuel gradually produces a loss of weight and possibly a shift in the center of gravity, it is possible for 

an aircraft to take off with the center of gravity in a position that allows full control, and yet later develop an 

imbalance that exceeds control authority. Calculations of center of gravity must take this into account (often part 

of this is calculated in advance by the manufacturer and incorporated into CG limits).

Center of gravity is calculated as follows:

 Determine the weights and arms of all mass within the aircraft.

 Multiply weights by arms for all mass to calculate moments.

 Add the moments of all mass together.

 Divide the total moment by the total weight of the aircraft to give an overall arm.

The arm that results from this calculation must be within the arm limits for the center of gravity that are dictated 

by the manufacturer. If it is not, weight in the aircraft must be removed, added (rarely), or redistributed until the 

center of gravity falls within the prescribed limits. 

Weight out of range

Few aircraft impose a minimum weight for flight (although a minimum pilot weight is often specified), but all 

impose a maximum weight. If the maximum weight is exceeded, the aircraft may not be able to achieve or sustain 

controlled, level flight. Excessive take-off weight may make it impossible to take off within available runway 

lengths, or it may completely prevent take-off. Excessive weight in flight may make climbing beyond a certain 

altitude difficult or impossible, or it may make it impossible to maintain an altitude.

1.16.6 Flying over Gross Weight28

“The problem with operating over maximum gross weight is more one of structural integrity than legality. 

Engineers rate each load-bearing structure with a certain maximum load. In the case of airplanes, that load is 

expressed in terms of G‟s. In the normal category, the FAA rates aircraft as capable of withstanding G loads of 

3.8 in normal operations (above which the structure may be damaged) and 5.6 maximum (beyond which the 

structure will likely fail). To use a simple example, a normal-category aircraft approved for a 4,000-pound gross 

weight in the normal category would have a theoretical maximum structural load-bearing capacity of 22,400 

pounds. (5.6 x 4,000 pounds). If you loaded the same airplane to 5,000 pounds gross weight, the maximum load 

capacity doesn‟t change, so you would reduce the G-limit from 5.6 to only 4.5G‟s (22,400 / 5,000).

 

28 Excerpt from Plane and Pilot march 2011 Edition, Bill Cox, Senior Editor.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 37

No pilot want to fly a damaged airplane, so the more typical limitation is the lesser one, 3.8 G‟s. Here the load 

limit works out to 15,200 pounds at 3.8 G‟s but the G-limit is now down to 3.1 G‟s at the higher weight. Another 

problem with flying an airplane well over gross weight is that while it will still fly, flight characteristics may be 

severely compromised in terms of roll rate, pitch response and performance. Climb rate may be seriously 

reduced, and service ceiling may be equally poor. Cruise speed and range also will be reduced.”

1.16.7 Airplane Performance

Eyewitnesses‟ statements were used to estimate the airplane‟s performance, flight path and altitude at impact (See 

figure 3 and eyewitnesses statements 1.1.4). The airplane‟s pitch angle and bank angle at impact were also 

established based on eye witnesses‟ statements (section 1.1.4).

1.17 Organizational and Management Information

No organizational or management information presented here as Acklins Blue Air Charter was not an authorized 

or recognized Air Operator Certificate Holder certified by the Bahamas Civil Aviation Department.

1.18 Additional Information

1.18.1 Acklins Blue Air Charter

Post accident investigations uncovered that Acklins Blue Company was founded in 1994 by owner and proprietor 

Mr. Nelson Hanna. Although Acklins Blue Air Charter advertised its services as a Charter company see Appendix 

5.3, Appendix 5.4 and Appendix 5.5) in contravention of Bahamas Civil Aviation (Safety) Regulations (CASR 

2001) Part X, Regulation 67 (1)(2) and (3) and more specifically 67 (2)(a) (See Appendix 5.13) Acklins Blue Air 

Charter did not obtain the required certification to operate as a certified air operator certificate holder as required 

by CASR 2001 Part X, Regulation 68 (See Appendix 5.14). 

C6-NLH, a 1981 Cessna 402C aircraft serial number 402C0458 was previously registered in the United States of 

America (US) as N68361. It was deregistered from the US registry on November 27, 2002 and registered in the 

Bahamas On December 05, 2002. C6-NLH was insured by Hayward Aviation Limited under a policy issued to 

Acklins Blue for commercial use, on demand charter, and insured for loss or damage to aircraft, third party and 

passenger legal liability and pilot personal accident insurance. Policy listed aircraft maintenance contracted out to 

an entity called Nixon Aviation. The policy lists the aircraft based at Executive Flight Support, Lynden Pindling 

Int‟l Airport. 

Aircraft utilization listed in the previous 12 months was 400 Hours. One provision of the policy was that recurrent 

training for the pilot was to be carried out every six (6) months. No records for the pilot were made available to 

verify whether this requirement for recurrent training was fulfilled by Mr. Hanna to meet the requirements of his 

insurance policy. The policy was executed 5 December, 2009 and was to expire 4 December, 2010. Mr. Hanna‟s 

flight times were listed as in excess of 12,000 hours with more than 10,000 hours on type (402C).

1.18.2 CAD Oversight of Acklins Blue Air Charter

At the time of this accident, CAD oversight of aviation in the Bahamas, (which is carried out by the Flight 

Standards Inspectorate (FSI), located at Lynden Pindling International Airport) was not conducted of Acklins 

Blue Air Charter (ABC) as ABC had not initiated or completed the certification process29 as required for an Air 

 

29 BAHAMAS CIVIL AVIATION (SAFETY) REGULATIONS SUBPART A: GENERAL

12.001 APPLICABILITY

(a) This Schedule applies to the carriage of passengers, cargo or mail for remuneration or hires by persons whose principal place of 

business or permanent residence is located in The Bahamas.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 38

Operator Certificate (AOC) holder certified under Bahamas Civil Aviation (Safety) Regulations (CASR 2001) 

Part X 67 and 68 (See Appendix 5.13 and Appendix 5.14) and Schedule 12.01530

Investigations uncovered that advertisements were circulated and on the internet advertizing C6-NLH as being 

operated in commercial air transportation by ABC airlines, located in the Executive Flight Support terminal at 

MYNN, offering personalize air transportation services throughout the Bahamas and to destinations in Cuba, the 

Dominican Republic, Cayman Isles and the Turks and Caicos Islands. Regular service was also offered to 

Eleuthera and Harbour Island using “properly maintained and insured 402C aircraft which can seat up to nine 

passengers.” (See Appendix 5.3, 5.4 and 5.5 for Acklins Blue Companies website information).

CAD / FSI mandate is surveillance of certified AOC as per CASR 2001 Schedule 12. As ABC was not an AOC 

holder authorized by these regulations and schedules, no surveillance by CAD/FSI was conducted. C6-NLH was a 

private aircraft owned by an individual and registered to a company named Lebocruise Air Limited which is also 

not an authorized AOC holder certified under the provisions of CASR 2001 Schedule 12.

1.18.5 Performance Category

The Cessna 402C aircraft was certified for single pilot operation within Performance Group C.

1.18.6 Emergency Procedures

The emergency procedures relating to the power loss contained within the Cessna Information Manual for the 

Cessna 402C see Appendix 5.10 Engine Failure after Take-off.

1.18.7 Pre accident CAD Actions

Several months prior to this accident, the Flight Standards Inspectorate established a proactive campaign where 

information was shared with the daily newspaper and other media outlets. Several articles were written and the 

department took the message to the airwaves via talk show and media houses warning the general public about the 

dangers of travelling with unauthorized / uncertified persons claiming to be legal air carriers. Numerous posters 

were strategically placed at Fixed Base Operations and the General Aviation Center warning about the dangers of 

engaging in commercial air transportation using the services of unauthorized air carriers. 

The Flight Standards Inspectorate additionally, engaged the assistance of the Airport Authority and NAD with 

meetings and strategic planning on ways to curb the incidence of unauthorized air charter operators. List of all 

authorized air charter operators were distributed to the media, Fixed Based Operators and other stake holders at 

MYNN. Additionally, The Flight Standards Inspectorate increased airside surveillance of areas frequented by 

general aviation traffic and possible area of unauthorized air charter operations.

 

(b) This Schedule of the regulations prescribes requirements for the original certification and continued validity of air operator certificates 

(AOC) issued by The Bahamas.

30 BAHAMAS CIVIL AVIATION (SAFETY) REGULATIONS SUBPART B: AIR OPERATOR CERTIFICATE

12.015 COMPLIANCE WITH AN AIR OPERATOR CERTIFICATE

(a) No operator may operate an aircraft in commercial air transport unless that operator holds an AOC for the operations being conducted.

(b) No person may operate an aircraft in commercial air transport operations that are not authorized by the terms and conditions of its AOC.

(c) The AOC holder shall, at all times, continue in compliance with the AOC terms, conditions of issuance, and maintenance requirements 

in order to hold that certificate.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 39

1.18.8 Post Accident Recommendations / Safety Alerts Issued

As a result of the accident involving C6-NLH on October 5, 2010,

1. Alert SA/A10-01312/001/10-9-10 was issued to Stakeholders at MYNN which includes Airport 

Authority, NAD, Civil Aviation Department, ATC, Odyssey Aviation, and Executive Flight Support in 

reference to Incomplete Flight Plan information and Inadequate security procedures that exists at Fixed 

Base Operations. (See Appendix 5.9 Alert). Additionally, correspondences were addressed specifically to 

Airport Authority, CAD and NAD outlining the inadequate security procedures and the need for 

improvement.

2. Alert SA/A10-01312/002/10-9-10 was issued to the Flight Standards Inspectorate addressing the need to 

amend its information gathering document system so that it captures information that would be useful 

during the investigation of accidents of Bahamas Registered aircraft (See Appendix 5.18). This was 

issued as a result of the unavailability of the historical aircraft records for C6-NLH. 

Its unavailability has impacted the investigation as there is no information available to support or verify 

whether the aircraft was being adequately maintained in accordance with Bahamas Civil Aviation 

(Safety) Regulations. 

1.18.9 Post accident Airport Authority Actions

Several post-accident meetings were held between the Airport Authority and stakeholders at MYNN (Executive 

Flight Support and Odyssey Phoenix Aviation). Airport Authority reports meetings and follow up meetings were 

accomplished and progress was being made with the construction and implementation of corrective action for

deficient items brought to light by recommendations put forward by the safety alert SA/A10-01312/10-9-10 

issued by the investigation team.

As a result of the Alert recommendations;

 An airport security program was developed by EFS

 An airport personnel training program was developed by EFS

The Airport Authority commits to monitoring the progress of the implementation of recommendations put 

forward by Alert for both Executive Flight Support as well as Odyssey (Phoenix Aviation).

1.18.10 Post accident CAD /FSI Actions

Post-accident, the Flight Standards Inspectorate has;

 Amended application for Certificate of Airworthiness to capture information that can establish a baseline 

history of Bahamas registered aircraft in the event of an accident or incident and historical information is 

not available or lost. This amendment addresses issues raised in Alert SA/A10-01312/002/10-9-10.

 Increased surveillance of General Aviation Center and all Fixed Based Operators.

 Strategically placed more flyers and brochures in the media as well the General Aviation and Fixed Based 

Operations warning about the dangers of flying with unauthorized air carriers.

 Increased its manpower by the hiring of two (2) additional aviation safety operations inspectors.

 Increased its presence by extending its work schedule to include surveillance from 6am to 6pm, Monday 

to Friday and on Saturdays and all holidays.

 Increased surveillance to include other islands in the Bahamas where reports of uncertified air carriers 

exist.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 40

1.18.11 Post accident EFS Actions

On December 10, 2010 Executive Flight Support submitted to the Airport Authority and the Nassau Airport 

Development Company (NAD) a draft copy of its Security Program as well as its Personnel Training Program 

which outlines and accounts for deficiencies discovered during the investigation and outlined in Safety Alert 

issued. A copy of the program is in possession of the investigation team and is not included in this report. The 

Airport Authority commits to monitoring the progress of the implementation of recommendations put forward by 

Alert reference Executive Flight Support.

1.18.12 Post accident NAD Actions

On November 18, 2010 NAD in its commitment to address the issues raised in Safety Alert issued to them, 

advised The Flight Standard Inspectorate that it had amended the Civil Aviation Department Form 63A1 back to 

its original version as outlined in Aeronautical Information Publication (AIP) figure ENR 1.10.1. This amendment 

would once again require that all items 1-22 on form 63A1 is now completed by person completing form 63A1.

This amendment would now required that pilots once again list all persons onboard the aircraft prior to takeoff –

this should aid in search and rescue efforts in the event of an accident in the future.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 41

2.0 Analysis

2.1 Overview

2.1.1 Flight reconstruction

The paucity of 'firm' data, particularly the absence of any flight data or cockpit voice recording, frustrated efforts 

to reconstruct precisely the flight path and sequence of events which led up to the accident. The tower controller's 

communication transcription provided significant data to determine the timing of key events to within a few 

seconds, but apart from the white smoke observed by the tower controller and his alerting the pilot of C6-NLH, 

the pilot gave no indication of a problem. The aircraft was subsequently given permission to return to the field 

and accept runway 27 if able. This instruction was acknowledged by the crew and attempts were made to return to 

a landing by the aircraft on runway 27. There was no radar or navigation system data with which to reconstruct 

the flight path and so, an approximation was compiled based on the recollection of numerous eyewitness reports. 

All reports seemed to be consistent with each other. The probable flight path is illustrated on the eyewitness 

statement on Figure 3 and Appendix 5.19.

The aircraft was below the weight category for which flight recorders are required to be fitted. The investigation 

was thus hampered by the lack of any record of the pilots' conversation, including routine and emergency 

checklist actions. It is highly likely that any such record would have added greatly to the understanding of this 

accident. Existing airworthiness requirements for modern aircraft in this category require the carriage of both a 

Flight Data Recorder and a Cockpit Voice Recorder, but only if they are multiengine turbine powered and has a 

maximum approved passenger seating capacity of more than nine. The 402C, having piston engines and not more 

than 9 passenger carrying capability, was not obliged to meet this requirement.

The accident flight was the second flight for C6-NLH on 5 October, 2010. There was no evidence of pre-existing 

failures or malfunctions in the airplane, its components or its system. However, the client on the first charter flight 

of the day on C6-NLH reported to investigators that during the engine run-up, at the runway before take-off, there 

was a serious discrepancy noted between indications of the left and right manifold pressure needles corresponding 

to the left and right engines respectively as evidenced on the manifold pressure gauge. Being a pilot himself, the 

client was concerned. The difference between both indications was approximately 90 degrees. The right manifold 

pressure needle responded accurately and timely when the right throttle lever was manipulated to a predetermined 

value, however the left needle lagged behind and eventually moved and caught up to the indications of the right 

engine despite both throttles being operated at the same time to that specific predetermined value. This 

discrepancy was brought to the attention of both pilots who “shrugged it off” and said “everything is ok” and “it 

will match up when full power is applied.” (See Eyewitness Evidence 1.1.4)

The pilot in command of record was properly qualified and certificated to operate the airplane on this flight. The 

specific detail of his training history was not available to the accident investigation team. No evidence was found 

that he was experiencing a behavioral or physiological impairment at the time that could have caused or 

contributed to the accident. At the time of the accident, the winds were 100 ̊ at 6kts and visibility was 7 miles 

with a forecast of a combination stationary front along with a surface trough across the northwestern and central 

Bahamas producing unstable weather through the forecasted period. Significant Weather section of the Bahamas 

Area Forecast over the central and northwest Bahamas indicated scattered to broken clouds from 1,200 feet to 

1,800 feet with towering cumulus and cumulonimbus clouds. Weather however, was not a factor in this accident.

The evidence indicates that the pilot of C6-NLH after departing runway 14 and being notified about the white 

smoke trailing behind the aircraft‟s left engine, decided to return to land at MYNN and accepted the controller‟s 

offer to land on runway 27 and did not continue on the appropriate flight path. The accident occurred while the 

pilot was making a left turn and extending his landing gear in the turn to intercept runway 27. ATC was not a 

factor in the accident.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 42

The investigation examined pilot actions to determine how a properly trained and qualified pilot with more than 

10,000 flight hours in type would allow the aircraft to turn into an engine reported as having a discrepancy, extend 

landing gear while in the turn, turn at such a low altitude and airspeed considering the mass and balance of the 

aircraft and lose control after take-off. 

The investigation also focused on why engine control switches for the right engine were found in the “OFF” 

position, whether they were intentionally or inadvertently switched off and if so when did it occur. The 

investigation also considered whether the second-pilot31 had a role in the decision making process that resulted in 

the accident. Additionally, the voice of the person that was making radio transmission with ATC was not the 

voice of the pilot and assumed to be the second pilot.

2.1.2 Wreckage Analysis

The aircraft was in the correct configuration for flight following reports of white smoke trailing behind its left 

engine. It had gear and flaps retracted initially right after becoming airborne according to eyewitness reports. The 

impact evidence showed excessive angles of bank and nose down pitch. This confirmed eyewitness evidence that 

the pilot initiated excessive bank angles, and extended landing gear in the turn, in an attempt to return to a landing 

on runway 27. The rate of descent was very high at impact which would account for the extent of damage suffered 

by the nose of the aircraft, nose landing gear, windshield, fuselage, right elevator and stabilizer and right wing and 

its attachments (wing tip, aileron).

Both fuel selector valves were found at the "OFF" position and a reason for both to be so selected is not readily 

apparent. It is possible that had the pilot not intentionally selected them to that position, it might well have been 

moved by airframe distortion during the crash. According to eyewitness reports, the aircraft engine continued to 

run for approximately 10 seconds after impact. This would indicate that the engine was producing some power at 

impact. It is likely that the fuel selector cables were pulled during impact and / or recovery process.

2.1.3 The Initiating Event

The first perceived abnormal event in the sequence leading to the accident was the observation of white smoke

and the abnormal sounds like an engine backfiring as reported by eyewitnesses. Also, as reported to the aircraft by 

ATC, white smoke was observed trailing behind the left engine of the aircraft. It is reasonable to believe that both 

engines were producing power, as the aircraft, prior to being notified of white smoke trailing behind the left 

engine and thereafter, never reported any malfunctions or advised of any emergency. Provided that one engine 

was producing full power and the other had failed and been correctly identified and its propeller feathered, if 

properly flown, the aircraft should have been able to climb, albeit slowly, and subsequently make a safe landing 

back at MYNN. Therefore, the damage within the left engine would not make an accident inevitable. It was the 

loss of thrust from the right engine, reduced horsepower on the left engine, and extension of the landing gear in a 

turn, the excessive rate of bank and airspeed decay that led to the loss of control. Consequently, some of the 

following analysis concentrates on the probability the pilot mishandled the left engine (possible) failure and in his 

haste to do something he inadvertently misdiagnosed and secured the wrong engine (right operating).

During the post accident investigation, investigators observed that the left and right magneto switches of the right 

engine as well as the alternator switch for the right engine were found in the “OFF” position. The auxiliary fuel 

pumps as well as both left and right fuel selector valves located between the pilots‟ seats were also found in the 

"OFF" position. Questions arise as to whether the pilot, possibly in his haste to do something, accidentally shut 

off electrical power to the right engine instead of the left engine as the left engine was the one reported as 

“emitting white smoke.” It is not known whether the right engine was shut off intentionally or inadvertently by 

the pilot, and if so, when in the chain of events did this occur?

 

31 Co-pilot / second (ramp agent at EFS states there was a copilot on board C6-NLH who loaded the luggage on the aircraft)
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 43

This analysis will focus on the pilot‟s decisions and performance that led to this accident. Also, focus will be 

made on the left engine # 2 cylinder which showed signs of mechanical failure. Questions arise as to when this 

cylinder failed and what impact, if any; its failure would have on total engine performance? Was its failure 

enough to cause an airplane to fall from the sky or did other factors play a role in the aircraft not being able to 

maintain altitude once the #2 cylinder failure occurred?

2.2 Other Factors

2.2.1 Aircraft Loading

In the context of this accident, the precise weight of the aircraft would have been relevant to the final outcome of 

a single engine failure. However, post accident calculations, which included the recovered luggage, fuel on board 

and passengers have revealed that the aircraft was over the maximum weight allowed for takeoff (6,850 pounds)

by more than 500 pounds. (See 1.16.4)

2.2.2 Pre-take-off Events

The crew carried out final preparations for the flight without much help from the ground support staff at EFS. 

Apart from a ramp agent who collected and placed a box on the aircraft, the two pilots performed all the routine 

tasks such as preflight inspection, luggage loading and embarkation of the passengers. There were no ground 

crewmen or marshaller to oversee the starting and taxiing phases and no need for either. Consequently there were 

no eyewitnesses to engine starting, aircraft seating assignment or which pilot occupied which seat.

A pilot who was in line for take-off after the C6-NLH, reported that the pilot took an unusually long time at the 

holding point doing the pre take-off run up checks. (This may have been as a result of the previous reported 

abnormality with the manifold pressure indication or any other number of reasons).

Other eyewitnesses reported aircraft abnormalities prior to takeoff. They reported hearing noises as if the aircraft 

was backfiring. Eyewitnesses interviewed were not able to determine if the backfiring noises were heard when the 

aircraft was on the take off roll or prior to the aircraft taxiing into position for takeoff. The backfiring noises heard 

could have been from the pilot conducting his pre-takeoff checks prior to taxiing into position for takeoff. These 

checks which the pilot habitually carried out prior to takeoff, required the speed of each propeller to be increased 

before the feathering mechanism was exercised momentarily, possibly more than once for each propeller, and for 

each propeller in turn. These checks result in the propellers slowing down and then recovering speed over a 

period of two or three seconds. 

The main change in perceived noise results not from the change in rotational speed, but from the changes in 

propeller blade angle which provoke the changes in rotational speed. These checks are unlikely to result in 

misfiring but the magneto test that follows may cause changes in the sound of a smooth running engine. Each 

engine has two magnetos (spark generators) and each cylinder has two spark plugs. During the engine checks one 

magneto is temporarily isolated to assess the engine‟s ability to run on the other ignition system. Occasionally 

one or more of a set of spark plugs may be contaminated which results in some rough running which is not 

evident when running on both magnetos. The discrepancy can often be cleared by increasing engine RPM or 

temporarily leaning the fuel to air ratio of the engine mixture, which may provoke some misfiring for a few 

seconds.

As eyewitness location on the field could not be determined when the misfiring noise was heard and other 

eyewitness close to the point of lift off of the aircraft not reporting any misfiring noise or abnormalities other then 

observing the white smoke, it seems likely that any engine malfunction noises were temporary and associated 

with pre-takeoff engine checks or spark plug contamination.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 44

2.2.3 Flap Position

Whether the aircraft became airborne with the wing flaps retracted or at the take-off position could not be 

positively determined. However, post impact observation noted the flaps were flush with the trailing edge of the 

left and right wing respectively. The principal factors relevant to the choice of flap setting are runway length, 

take-off weight and obstacles in the departure direction. The aircraft has a shorter take-off ground roll with flaps 

extended but if the flaps are up for take-off, the engine failure procedure during initial climb is much simplified 

and the one engine inoperative climb performance is improved. 

Runway 14 at Lynden Pindling International Airport is far longer that the predicted lengths required by a Cessna 

402C at maximum take-off weight, to accelerate to take-off speed and then decelerate to a stop on the runway. 

Consequently, take-off with the flaps retracted would not have contributed to the accident sequence. However, 

take-off with the flaps extended could have complicated the engine failure procedure if the power loss had 

occurred before the flaps were raised at the customary height because of the extra drag associated with flap 

deployment.

2.3 Event Timing

It is reasonable to assume that with other aircraft behind him waiting to depart, the pilot would have commenced 

his take-off as soon as ATC clearance to do so had been acknowledged by the second pilot. There was a slight 

delay from the time the aircraft was cleared for take-off until the time it actually departed. The aircraft became 

airborne and then flew in a normal take-off configuration, and then at rotation, more white smoke was observed 

trailing behind the left engine. There was a brief period of climbing flight followed by a gradual bank to the left, 

which turned into a steep almost perpendicular bank followed by a steep nose down descent into the lake as 

control was lost. The aircraft was airborne for approximately 90 seconds, during which time the pilot 

acknowledged the white smoke and accepted runway 27 for a return.

2.4 Before the Initiating Event

2.4.1 The Take-off. 

According to eyewitnesses and the ATC controller, the aircraft made a normal take-off run where white smoke

was observed from the initiation of the run. The 

aircraft was cleared for take-off from intersection 

Foxtrot of runway 14.

The aircraft's ground roll started approximately 

2,000 beyond the threshold of runway 14,

(Intersection Foxtrot) and it became airborne 

either just after Intersection Bravo 1 or just about 

or after the intersection of runway 32/14 and 

runway 27/09 (See Appendix 5.15 and Appendix 

5.19 Airport Layout MYNN). Just after becoming 

airborne the landing gear were retracted as in a 

normal take-off.

The runway distance from the line-up position 

(Intersection Foxtrot) to the intersection where the 

aircraft became airborne (Intersection Bravo 1) was approximately 7,000 feet. The normal take-off distance 

performance data in the Cessna Information Manual, both engines operating (Figure 10) was interpolated to get a 

base line estimate of how much runway was required for the take-off, using the maximum weight allowed on the 

aircraft at take-off of 6,850 pounds and to clear a 50 ft obstacle.

Figure 10 Normal Take-off Distance
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The performance data with conditions; wing flaps retracted, weight of 6,850 pounds, take-off to clear 50 ft. 

obstacle indicated airspeed of 95KIAS a pressure altitude of sea level and temperature 30C(86F), was used in 

this computation (temperature for the day and around the time of the accident was 81F).

Using these figures conservatively the ground roll for the aircraft should have been approximately 2,040 feet and 

if there was a 50 ft. obstacle that needed to be cleared, the ground roll of approximately 2,560 feet would be 

needed to clear that obstacle. These distances are determined using a new aircraft flown by a manufacture's test 

pilot. The measured take-off is performed from a stationary start with wheel brakes on and full rated power on 

both engines. This method is often impractical at a busy airport and unnecessary at airports with long runways. 

Furthermore, the reliability of piston engines such as that fitted to this aircraft, benefit from gentle changes in 

power and such gentle changes can add as much as 100 feet or more to the take-off run.

If a nominal increase of 100 feet for gentle power application is added to the Cessna Manual figures, the take-off

ground roll should have been in the region of 2,140 feet (with the 50 ft. obstacle clearance ground roll, will use 

2,800 ft. conservatively). The difference between the calculated and reported ground roll distance is in excess of 

4,000 feet which is significant. Nevertheless, where runway length is not a limiting factor, it would be reasonable 

for the pilot deliberately to remain on the runway whilst accelerating from the recommended safe single engine 

speed of 95 KIAS to the one engine best rate of climb speed of 104 KIAS. The distance travelled during this 

acceleration could have been consistent with the extra 4,000 feet. Low engine power is an alternative explanation 

for the increased ground roll but it would have had to be a near symmetric loss of power for the pilot not to have 

noticed it. The discrepancy reported with differential in manifold pressure readings could also be an explanation 

as to the extended runway use. An alternate explanation might be that the pilot deliberately chose not to use full 

power for the take-off given the length of the runway. However, this would have been inconsistent with operating 

practices therefore a deferred rotation at 104 KIAS seems the more likely explanation given the manifold pressure 

reading and amount of passengers and weight that may have been loaded on the aircraft. 

Whatever the reason for the prolonged ground roll, C6-NLH became airborne from MYNN and the controller 

who saw the white smoke as the aircraft climbed out advised the aircraft and asked him to return and gave him the 

option of runway 27. Had there been a malfunction on the runway or immediately after lift-off, and whilst the 

landing gear was still extended and had the full length of the runway been utilized, the pilot could have adopted 

the action recommended in the Cessna Manual which was to close both throttles and land straight ahead on the 

remaining runway length. Therefore, it seems probable that both engines were operating normally during the 

take-off ground roll. The pilot did not declare an emergency. If he had perceived an engine failure, he might have 

said so because this would have provided the air traffic controller with important information. Since he did not 

specifically mention an engine failure, it is possible that he was unsure which engine was malfunctioning, 

particularly as the left engine must have been producing some power or else the aircraft could not have climbed.

2.4.2 The Initial Climb

Assuming the pilot became airborne at 108KIAS with the flaps retracted; his subsequent action would have been 

to raise the landing gear. He probably intended to accelerate to 120KIAS before reducing engine power to the 

recommended cruise climb setting. It is possible that the act of reducing power provoked a malfunction in the left 

engine and hence the failure of the number 2 cylinder and that a symptom of that malfunction could also be the 

backfiring heard by the eyewitnesses.

2.5 The Initiating Event

2.5.1 The position of the aircraft when the misfiring was heard.

The eyewitnesses were uncertain precisely where the misfiring had occurred but had it not been during the pretakeoff checks, it may have been somewhere after takeoff and prior to the decision to return for a landing.
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None of the eyewitness on the ground reported seeing any flames or separated components from either engine so 

there was no evidence, apart from post accident examination of the engines, to indicate the source of the failure 

and engine noise. The examination found no faults within the right engine but mechanical failure of the number 2 

cylinder of the left engine. Thus it is possible that the misfiring or noise heard by the eyewitnesses and possibly 

the crew, if they did in fact hear it, or felt the loss of thrust came from the left engine but sounded or felt like it 

came from the right engine hence the decision to secure the right engine and not the left.

Another possible explanation for the misfiring could be weather related. For instance, the aircraft had recently 

returned from a charter to Treasure Cay where they were unable to land due to the intense weather and rain. 

Water may have made its way into the fuel tank during this time or possibly during or after refueling. Although 

the pilot‟s standard preflight checks include a fuel check and the draining of any water from the tanks, there was 

no way of knowing if the crew had drained any water from the tank sumps. If they had not, a small quantity of 

water could have entered the fuel lines during taxiing or takeoff and made its way to the engine. Once in the 

injector lines, it could have cause a temporary interruption in power followed by misfiring or a bang from the 

exhaust as engine power is restored. No inference that this happened is intended. It is simply a plausible 

explanation and there might be other reasons for a temporary malfunction or misfiring noises heard.

2.6 Practical engine failure identification

In a twin engine light aircraft the generally accepted method of determining which engine has lost power is by 

rudder foot loads and displacement. In the event of one engine losing power, the aircraft tends to turn towards the 

failing engine and this undesired yaw must be corrected by applying rudder, which pilots learn to apply 

instinctively. If one of the Cessna 402 engines were to lose all its power immediately after take-off, the rudder 

foot load would be heavy and the displacement significant it is difficult to mistake which foot is applying load to 

the rudder pedal. Once this action has been taken, pilots use a simple phrase such as „dead foot, dead engine‟ to 

identify the defective engine. Consequently, if an engine were suddenly to lose all its power output, there would 

be no need to look at the engine instrumentation to determine which engine has failed. Once the defective engine 

has been identified, the pilot should complete the appropriate actions listed in the Cessna Information Manual. 

An engine failure during takeoff is the most critical time for a failure and the procedure is complex. The vital 

actions must be carried out swiftly and recalled from memory.

The pilot did not declare an emergency with ATC. If he had perceived an engine failure he might have said so 

because would have provided the air traffic controller with important information. Since he did not specifically 

mention an engine failure, it is possible that he was unsure which engine was malfunctioning, particularly as the 

left engine must have been producing some power after the misfiring noises were heard or else the aircraft could 

not have climbed.

2.7 Events between the initiating event and the left turn

2.7.1 Control of Bank Angle

As the Cessna Information Manual states, straight flight on the power of one engine is best achieved by banking 

5 ̊ towards the engine under power. This bank angle would barely be noticeable to eyewitnesses so it was not 

possible to determine whether the pilot adopted this procedure (if he did in fact have an engine failure). However, 

given his experience and qualification, the pilot would certainly have known of its relevance to his predicament as 

well as the requirement not to use too much bank in either direction. In this context, 10 ̊ of bank would be too 

much for straight flight and more than 30 ̊ bank would have been excessive for a deliberate turn.

2.7.2 Climb Performance

Eyewitnesses were generally consistent in their statements that the aircraft was still climbing after it had passed 

over the perimeter road towards the lake until just before it increased its bank to the left, while extending its 
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landing gear. Some eyewitnesses estimated the aircrafts height at the start of the turn as about 150 to 300 feet. 

However, if the eyewitnesses‟ estimates are reasonable, the aircraft must have climbed between 100 and 300 feet 

between the runway and the start of the turn. Consequently, for the aircraft to have continued climbing after 

crossing the road as many witness reported, the left engine must have been producing some useful power. In 

simple terms, the loss of power on the left engine, if there was one, must have been more progressive than sudden.

2.8 Condition of the engine in flight

2.8.1 Right Engine

No mechanical evidence was found regarding a malfunction of the right engine. The probability that a subtle 

discrepancy would occur coincident with the discrepancy suffered by the left engine is highly unlikely. 

Corroborating evidence that the pilot may have perceived a discrepancy within the right engine was found within 

the wreckage. Both fuel selectors were found in the “OFF” position. Assuming the pilot became airborne with 

each selector in its respective position (left selector valve to left engine and right selector valve to right engine), if 

he moved it, the only reason for him to do so would be if he thought a discrepancy with the left engine might be 

related to its fuel supply consequently turning the left selector to the off position instead of the right engine 

position (or cross-feed position). In his haste, he may have inadvertently also turn the right selector valve to the 

“OFF” position when trying to secure what he may have later perceived to be a discrepancy with the right engine 

instead. He therefore may have inadvertently secured the right engine as both left and right magneto switches of 

the right engine were found in the “OFF” position. Alternator switch for the right engine as well as the Battery 

switch was found in the “OFF” position. Auxiliary fuel pump switch for the right engine was also found in the 

“OFF” position.

2.8.2 Operating the wrong propeller lever

Usually the first three actions for shutting down a reciprocating engine are to close the throttle, select the RPM 

lever to feather and select the mixture to cut-off. On some aircraft types this involves retarding three of the six 

engine control levers, working from left to right, retarding alternate levers. However the engine securing 

procedure in the Cessna Information Manual is slightly different; it states the order as throttle, mixture and then 

propeller lever. (See Appendix 5.10). The difference in the order is unlikely to be significant provided that the 

pilot operates the lever swiftly, but it is a complication that slightly increases the probability of operating the 

wrong lever.

The possibility that the pilot intended to shut down the left engine but operated the right engine levers and control 

switches by mistake was considered. If the pilot had accidentally moved the wrong lever, it seems likely that he 

would have noticed his mistake in time to reverse his action. He would have heard the change in propeller noise 

and experienced a yaw to the right. The only contra-indication to this assumption would be the rudder deflection 

and perhaps the engine instruments. The confirmatory signs for his assumption would have been the power 

fluctuations from the right engine. A situation where one engine‟s power is fluctuating may be difficult to resolve 

for two reasons; firstly the propeller governor tends to keep the propeller RPM constant; and secondly, when both 

engines have similar manifold pressures, one needle is masked by the other which overlays it. If the fluctuations 

are rapid, the pilot may be unable to read the „L‟ and „R‟ symbols on each needle of the twin-needle engine 

instruments. (See Appendix 5.17)

2.9 Events during the Turn

To some witnesses the aircraft appeared to maintain height for a few seconds during the early part of the turn 

before it began to descend: to others it had started to descend shortly before the turn began. Whichever 

recollection is correct, the aircraft had obviously stopped climbing. Moreover, the high nose attitude in the turn 

reported by some eyewitnesses would have been inconsistent with sustained flight on one engine. 
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The landing gear was extended during the turn and the bank angle of the aircraft was almost perpendicular to the 

ground as reported by some eyewitnesses‟. An attempted turn towards the airfield was also bound to reduce the 

aircraft‟s climb performance. Somewhere between the time the aircraft departed and the time it crashed the right 

engine was secured. If the pilot had fully realized his predicament, at that moment he had only two choices: either 

a forced landing in the lake straight ahead or a gliding turn back to the airport. Even if he was as high as 500 feet, 

(and none of the eyewitnesses thought it was that high) given his distance and location from the runway, a gliding 

return was an unrealistic choice. The eyewitness reports of a rapid increase in bank angle and the aircraft‟s nose 

pitching into a steep descent are consistent with total loss of control. Moreover, there can be little doubt that the 

aircraft stalled; the stall speed in level flight was in the order of 80 KIAS but any attempt to turn tightly was likely 

to increase the stall speed and lead to an abrupt loss of control. The observation of the eyewitnesses when used to 

calculate the aircraft‟s height, equated it to a maximum height of approximately 100 to 300 feet above the ground. 

Once it had stalled at that height and without power, a crash was inevitable. The rate of descent was high and 

penetrating the water of the lake did much to disrupt the structural integrity of the airframe. The evidence does not 

indicate which engine failed (if any), but it does indicate the importance of ascertaining when the pilot secured the 

right engine. 

2.9.1 Loss of Control

Eyewitnesses‟ reports of a rapid increase in bank angle and the aircraft‟s nose pitching into a steep descent are 

consistent with total loss of control. Moreover, there can be little doubt that the aircraft stalled; the stall speed in 

level flight is in the order of 80KIAS but any attempt to turn tightly was likely to increase the stall speed and lead 

to an abrupt loss of control. Eyewitnesses‟ accounts states that the aircraft was approximately 150 to 200 feet and 

in some estimation as high as 300 feet above the ground. Once it had stalled at that height and without sufficient 

power a crash was inevitable. The extension of landing gear during this tight turn only further helps to increase 

the inevitable loss of control.

2.10 The loss of power from the left engine

The left engine had suffered a major mechanical failure with the number 2 cylinder and much of the effort in the 

engineering investigation was devoted to understanding what had led to that failure. There was evidence of preexisting wear. The existence of fatigue displayed long term wear characteristics but no short term traumatic 

damage. A summary of left and right engine analysis follows and a full description of the engineering results 

contained in engineering reports appendix 5.1 and 5.2.

2.10.1 Summary of left and right Engine Analysis

On October 6, 2010 C6-NLH was recovered from the waters of Lake Killarney. Both engines remained attached 

to the fuselage. The wreckage was stored under quarantine at a hanger at Lynden Pindling International Airport, 

Nassau, Bahamas. Both engines were removed from the fuselage and photographed in their recovery state. Both 

engines were prepared for shipping to TCM for a detailed examination prior to being placed in shipping 

containers. Prior to shipping the left engine, the No. 2 cylinder assembly and piston were removed, photographed 

and transported by hand to the NTSB Materials Laboratory, Washington DC, for a detailed examination. The No. 

2 cylinder, serial number 30213-3, had separated into two parts between the fourth and fifth fin from the barrel 

end, the lower part remaining attached to the barrel. And later research of the stamps, etching and other 

identifying marks established the original cylinder manufacturer as Engine Components Inc. (ECi), a division of 

Danbury Aerospace, both of San Antonio, Texas. The Right Engine was identified as TCM TSIO-520-VB Serial 

Number 290209 and Left Engine as TCM TSIO-520-VB serial Number 248270.

On October 9, 2011 preliminary inspections of both engines was accomplished by representatives of Teledyne 

Continental Motors at Lynden Pindling International Airport, Nassau, Bahamas. Additional photographs were 

taken evidencing the condition of the engines. Both engines were prepared for shipping prior to being placed in 

shipping containers. 
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The Left Hand Engine No. 2 cylinder had separated into two parts between the fourth and fifth fin from the barrel 

end; the upper major portion of the cylinder head and the lower portion which remained attached to the barrel. 

Additional photographs were taken of the stamps, etching and other identifying markings and forwarded to the 

NTSB. The research of the stamps, etching and other identifying markings established the manufacturer of the 

cylinder as ECi. ECi was notified of the accident and copies of the stamps, etching and other identifying markings 

was provided. ECi completed its research of the stamps, etching and other identifying markings and supplied the 

historical data on the birth and history of Cylinder Serial Number 30213-3. 

On October 18, 2010, the No. 2 cylinder assembly of the left engine was examined by personnel from the 

National Transportation Safety Board (NTSB) Materials Laboratory, ECi (cylinder manufacturer) and the 

Bahamas Civil Aviation Department. 

2.10.2 Left Hand Engine No. 2 Cylinder Analysis

The Details below was taken from the NTSB MATERIALS LABORATORY FACTUAL REPORT.

Preliminary examination of the fracture faces revealed that they were partially covered by a combustion product.

 

The fracture faces are illustrated in Figure 2 with the 

head portions, the barrel, the piston, the exhaust 

valve and the intake valve identified. Examination of 

the fracture faces revealed two zones displaying 

different surface textures, one located predominantly 

on the exhaust side of the cylinder head. The zone 

within the purple dashed line was relatively smooth 

and the zone outside of the dashed line displayed a 

rough uniformly grainy surface. The purple arrows 

in Figure 2 indicate distinct crack arrest marks that 

were located within the smooth zone, consistent with 

fatigue.

The yellow arrow indicates a slightly darker arced area within the smooth zone and the blue arrows 

indicate radial lines that appeared to emanate from where the ends of the arced area abutted the crest of 

the barrel thread.

The fracture face around the smooth zone on the lower portion of the cylinder head was solvent cleaned 

and is illustrated in Figure 3 with the smooth zone contained within the purple dashed line. The 

cleaning revealed the darker arced area indicated by the yellow arrow which matched the darker arced 

area indicated by the yellow arrow in Figure 2 and is illustrated later in Figure 4. Examination of the 

smooth zone revealed that the fracture was relatively flat and oriented perpendicular to the axis of the

barrel; features also consistent with fatigue.
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Samples were removed from the 

cylinder head and the barrel for 

detailed examination and their 

sectional views are illustrated later in 

Figure 13. The purple dashed lines in 

Figure 3 indicate the location of a 

lower cylinder head sample identified 

as “LH” and a mating barrel sample 

identified as “B”. The white dashed 

line on the opposite side of the 

cylinder head in Figure 3 indicates a 

cut that was made in order to separate 

the lower head portion from the barrel 

so that sample “H”, indicated by the 

yellow dashed lines, could be 

removed. A mating sample of the 

upper cylinder head, identified as 

“UH”, was also removed and is 

indicated by the red dashed line in 

Figure 2.

The darker arced area indicated by the yellow arrow in Figure 3 displayed a relatively smooth fracture 

face that abutted the crest of the first thread on the barrel. The fractured face displayed arced crack 

arrest marks and ratchet marks15 consistent with fatigue. The darker arced area is illustrated in Figure 4 

with the barrel and the lower cylinder head portion identified. The red dashed line indicates a distinct 

termination of the darker area consistent with the engine not being operated for a significant time 

resulting in a cessation of crack propagation. The purple arrows indicate crack arrest marks within the 

darker area and outside of it. The red arrows indicate ratchet marks, within the darker area, that 

originate in the root of the cylinder head thread engaged with the first thread on the barrel. 
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The yellow arrows indicate ratchet marks, outside of the darker area, that also originate in the root of the 

cylinder head thread engaged with the first thread on the barrel. The blue arrows indicate ratchet marks 

similarly indicated by the blue arrows in Figure 2. The green arrows indicate residual anti-seize 

compound.

The locations of the identifications previously observed on the upper cylinder head portion are 

illustrated in Figures 5, 6 and 7. 

Figure 5. Side view of the upper head portion.

Figure 5 is a side view with the intake port, 

the rocker cover and the rocker gasket 

identified. The “up” direction, as installed, 

is also indicated. The white arrow 

indicates the serial number, 30213-3, 

consistent with the August 2008 cylinder 

history and the yellow arrow indicates the 

bell profile, consistent with the cylinder 

being the “FREEDOMTM” brand. 

The left image in Figure 

6 is a closer view of the 

rocker flange in the area 

indicated by the green 

arrow in Figure 5. The 

green arrow indicates the 

serial number 47932-06, 

consistent with the 

August 2006 cylinder 

history, and the white 

arrow indicates the 

cylinder head casting 

revision letter, “F”.

Examination of the rocker cover revealed that it was attached to the cylinder head by two screws that were found 

to be loose, consistent with the rocker cover being previously removed. The rocker cover displayed the SAP16 

logo, indicated by the red arrow in the right image in Figure 6, and the word “Millennium”, indicated by the white 

arrow in the right image. These SAP components are consistent with them being transferred from the SAP 

cylinder this ECi cylinder replaced, as indicated by the January 2010 cylinder history.
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Figure 7. The rocker space in the upper portion of the cylinder 

head.

The identifications previously observed in 

the rocker space are illustrated in Figure 7 

with a red arrow indicating the ECi logo, a 

purple arrow indicating the casting part 

number, a green arrow indicating the 

casting revision letter and a blue arrow 

indicating the Oberdorfer trapezium. The 

black arrow indicates the overhaul number 

41525-2, consistent with the January 2010 

cylinder history. The yellow arrow 

indicates a location on the intake valve 

retainer that displayed the identifications 

“SA35971” and “FAA-PMA”, consistent 

with it being an SAP product. 

As the August 2008 cylinder history 

indicated that the cylinder was overhauled 

by ECi and sold as a complete assembly, 

which included AEC valve assemblies, and 

the January 2010 cylinder history indicated 

that the cylinder overhaul included a valve 

and valve seat re-cut, not a valve assembly 

replacement, the valve assemblies were 

removed and examined for identifications.

 

Examination of the valve assembly components located p/n SA5399885 on the intake valve, p/n SA35971 on the 

intake retainer, p/n SA6438734A on the exhaust valve, p/n SA629117-1-E on the rotator and p/n SA652984D on 

the intake and exhaust rocker shafts, part numbers consistent with them being SAP products. No records were 

found to indicate when the ECi valve assembly was replaced by the SAP valve assembly. 
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Figure 8. Valve gear removed from the cylinder head 

and the piston extracted from the barrel.

The valve assembly components are illustrated and 

identified in Figure 8 with the piston, extracted from the 

barrel, and the piston pin, extracted from the piston. 

Removing combustion product from the crown of the 

piston revealed the part number 654840C, consistent 

with it being the appropriate TCM piston for the TCM 

model TSIO-520 engine and agreeing with the inserted 

number on the Airmark parts list in the January 2010 

cylinder history.

The disassembly process revealed a significant, tan 

colored deposit in the cylinder ports and on the valves 

reminiscent of soil. Such a deposit would not be present 

during normal operation but would be consistent with 

lake bed material being carried into engine cavities 

resulting from the aircraft impacting the lake bed. A 

sample of the deposit at the location indicated by the 

yellow arrow in Figure 8 was taken for the analysis 

detailed later.

Examination of the cylinder head included the 

injector indicated and identified in Figure 1. The 

injector is illustrated in Figure 9 with the outer 

fitting removed to reveal the inner fitting. The 

inner and outer o-rings are indicated and a blue 

arrow indicates a mostly tan colored soil-like 

deposit between the o-rings. The inner fitting was 

removed from the cylinder head and an 

examination revealed three mostly obscured holes 

in the reduced diameter between the o-rings. One 

side of the inner fitting displayed a partially clear 

hole and is illustrated in Figure 10 with the inner 

and outer o-rings identified. Figure 9. The injector assembly partially disassembled.
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Blue arrows indicate the deposit and a black arrow 

indicates a partially clear hole. The opposite side 

of the inner fitting displayed two mostly obscured 

holes and is illustrated in Figure 11 with the inner 

and outer o-rings identified. Blue arrows indicate 

the deposit and black arrows indicate the two 

mostly obscured holes. Examination of the central 

hole in the inner fitting revealed that it was clear 

of any obstruction. A sample of the deposit was 

taken for analysis and comparison with the sample 

removed from the intake valve, indicated by the 

yellow arrow in Figure 8. Removal of the sample 

revealed that there were 8 holes (four pair) in the 

inner fitting, suggesting that the cylinder would 

require eight holes to be operational and would 

not be functional with a majority of the injector 

holes obstructed. The presence of the soil-like 

deposit would also be consistent with being post 

impact and originating on the lake bed.

Details of Sample examination and testing available in attached section “NTSB MATERIALS LABORATORY 

FACTUAL REPORT”.

On January 18, 2011 both engines were examined at TCM, 2039 Broad Street Mobile, Alabama. The examination 

of the left engine was witnessed by representatives of TCM, Bahamas CAD, Danbury Aerospace, Airmotive 

Engineering Corporation, and Superior Air Parts, while the examination of the right engine was witnessed by 

personnel from TCM and Bahamas CAD.” 
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Final Report C6-NLH Page 55

2.10.3 Left Engine Serial Number 248270 Analysis

The engine exhibited impact damage, concentrated at the bottom components of the engine. The number 2 

cylinder head and barrel were separated both by a fracture surface and the threaded junction. The maintenance 

history of the engine was unknown due to the records not being available.

 

Component Observation

Starter The starter rotated by hand and was intact.

Starter Adapter

The starter adapter could not be rotated by hand. The assembly was intact and the 

scavenge pump gears and housing were intact and undamaged. The crankshaft to camshaft 

timing was verified by the alignment of the gear‟s timing marks.

Ignition Harness All leads were frayed or damaged shielding and exhibited normal operating signatures.

L/H Magneto The left-hand magneto cannot be turned through by hand. 12-23-08 Overhaul date. The 

unit was disassembled and found to be intact and contain corrosion.

R/H Magneto The right-hand magneto turned with associated binding. 12-23-08 Overhaul date. The unit 

was disassembled and found to be intact and contain corrosion.

Oil Cooler The oil cooler was intact and exhibited corrosion and impact damage signatures. Drake air 

overhaul. Additional numbers: 11-30-07, 445128, C-15387, 30449A, J07-6486-9.

Oil Pump

The oil pump drive was intact. The oil pump cavity contained light scratches and exhibited 

normal operating signatures. The oil pump gear teeth exhibited normal operating 

signatures. The oil pressure relief valve and seat contained no obstructions and exhibited 

signatures of proper seating.

Oil Filter The oil filter was intact and was not opened.

Throttle and Fuel 

Control Assembly

The unit exhibits corrosion and the levers were immovable by hand. Finger screen 

removed and no material was present. The unit was disassembled and there was corrosion 

present. The internal components were found to be intact and seating properly. The 

passages where open and unrestricted.

Fuel Pump

The fuel pump turned by hand, but with substantial resistance. The fuel pump drive was 

intact and undamaged. The fuel pump was disassembled to examine the internal 

components. The internal components were intact but exhibited a corrosive material.

Fuel Manifold 

Valve

The fuel manifold valve exhibited normal operating signatures. The manifold valve was 

disassembled to examine the internal components. A jell material covered a portion of the 

screen. The manifold valve plunger assembly was intact, secure and undamaged. There 

were no signatures of fuel stains or leakage in the vent chamber side of the diaphragm.

Fuel Nozzles and 

Lines

The number 2 fuel nozzle was not returned with the engine or cylinder. The fuel nozzles 1, 

3 and 6 were restricted the remaining were unrestricted and exhibited normal operating 

signatures. The fuel lines were intact and undamaged.

Spark Plugs

The number 2 cylinder sparkplugs were returned with the cylinder and were intact. The 

sparkplugs contained corrosion and combustion by-products. The spark plugs had normal 

wear signatures in accordance with the Champion aviation check-a-plug comparison chart.

Component Observation

Alternator The alternator turned through by hand and was intact. The drive coupling was intact and 

undamaged.

Oil Sump

The oil sump drain plug was not safe tied. The oil sump exhibited impact damage and was 

crushed. The oil sump was drained of oil and the amount was residual. The sump contained 

foreign material.

Oil Pick-up Tube & 

Screen

The oil pick-up tube exhibited impact damage. The oil suction screen was unrestricted.

Induction System The induction risers and balance tube exhibited impact damage and corrosion.

Cylinder #1 The spot putty was not evident on the cylinder hold-down nuts. The cylinder combustion 
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Cylinder #3 

Cylinder #4

Cylinder #5

Cylinder #6

chamber contained combustion and corrosive deposits. The cylinder bore was intact and 

corroded. The cylinder skirt was intact and undamaged. The intake and exhaust valve heads 

exhibited normal deposits and operating signatures. The rocker box area had an oil residue 

indicating lubrication to the overhead. The cylinder overhead components (valves, rocker 

arms, guides, springs, retainers and shafts) were lubricated and undamaged.

Cylinder #2

The number 2 cylinder was received separately from the engine. The cylinder head and 

barrel were separated both by a fracture surface and the threaded junction. Sections had 

been removed from the cylinder head and barrel by the NTSB Laboratory. The fracture 

surfaces were examined by the TCM and NTSB Metallurgical Laboratories. The intake 

and exhaust valve heads exhibited normal deposits and operating signatures. The cylinder 

overhead components (valves, rocker arms, guides, springs, retainers and shafts) were 

lubricated and undamaged. Head markings – AEC65385, 010, 020, 41525.2, 143071, 

G842G, 47932-06

No. 1, 3, 4, 5, & 6 

Piston, Rings and 

Pin

The piston head exhibited a normal amount of combustion deposits. These deposits had an 

appearance of exposure to moisture. The piston skirt was free of scoring and damage. The 

piston rings were intact, free in their grooves, exhibited normal wear and operating 

signatures. The piston pin and plug assembly was intact and undamaged.

#2 Piston, Rings 

and Pin

The piston was received separate from the engine. The piston head had been partially 

cleaned. The piston skirt was free of scoring and damage. The piston rings were not 

installed. The piston pin and plug assembly was intact and undamaged.

Lifter

Intake & Exhaust

The lifter faces were undamaged and exhibited normal operating signatures. The lifter 

bodies were undamaged and exhibited normal operating signatures.

Crankshaft

The crankshaft and counterweight assembly was intact. The connecting rod journals, main 

journals and thrust surfaces were undamaged and showed no signs of abnormal wear or 

lubrication distress. The crankshaft counterweight pins, plates and snap-rings were intact. 

The counterweights were undamaged and had free and unrestricted movement on the 

hanger blades. The gear bolts were tight and safe tied and the gear teeth were undamaged. 

The oil transfer passages were open and unrestricted. Alternator drive face gear teeth were 

intact and undamaged. The oil transfer collar was intact and undamaged. The oil transfer 

plug was tight and in position.

Component Observation

#1 Main Bearings

The #1 (rear) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

#2 Main Bearings

The #2 (intermediate) crankshaft main bearings exhibited fretting at their mating surfaces. 

The bearings were intact and exhibited an insignificant amount of contamination and hard 

particle passage. There were no signs of lubrication distress.

#3 Main Bearings

The #3 (intermediate) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

#4 Main Bearings

The #4 (intermediate) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

#5 Main Bearings

The #5 (front) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

No. 1, 2, 3, 4, 5 & 6 

Connecting Rod

The connecting rod assembly was intact and undamaged. The connecting rod nuts and 

bolts were intact and secure. The connecting rod bushing exhibited normal operating and 

lubrication signatures.

No. 1, 2, 3, 4, 5 & 6 The connecting rod bearing exhibited normal operating and lubrication signatures. The 
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 57

Connecting Rod 

Bearings

connecting rod bearings were intact and exhibited an insignificant amount of contamination 

and hard particle passage. There were no signs of lubrication distress.

Camshaft

The camshaft lobes exhibited normal operating signatures. The camshaft gear was intact 

and exhibited normal operating signatures. The gear bolts were tight and safe tied and the 

gear teeth were undamaged. Work order numbers: DSC11052-1, DSI9081-6.

Crankcase

The crankcase was intact. An epoxy material was present at the number 8 and 9 backbone 

(lifting eye) bolt bores. The cylinder bays were intact and undamaged. The number 2 main 

bearing support mating surfaces exhibited rough surfaces from fretting. The right-hand 

number 2 main bearing support lock-slot was elongated, indicating bearing shift. The 

remaining main bearing support mating surfaces were intact and exhibited no signs of 

fretting or bearing tang lock-slot elongation. The main bearing support diameters were 

intact. The oil galleys and passages in the left and right crankcase halves were intact, clear 

and unrestricted.

Accessory Gears The accessory gears had continuity. The teeth were undamaged and exhibited normal 

operating signatures.

Component Observation

Turbocharger

The turbocharger could not be rotated by hand. The turbine housing exhibited damage to 

the tailpipe flange. They were no signs of turbine housing crack or leaks. The turbine 

blades were intact. The center housing oil inlet and outlet fittings were intact and there

were no signatures of oil leakage. The center housing was intact and there were no cracks 

or exhaust leaks present. The compressor housing was intact and there were no cracks 

present. The compressor housing was attached securely to the center housing. The

compressor blades were intact and they exhibited minimal erosion signatures. Debris was 

present in the compressor wheel.

Controller The controller exhibits corrosion and the lever was immovable by hand. The lever was 

intact and secure.

Overboost Valve The overboost valve was intact and exhibited debris in its openings.

Wastegate The wastegate (exhaust by-pass) valve was in the full open position and the linkage was 

intact. The wastegate and actuator assembly was intact and undamaged.

Propeller Governor The propeller governor could be rotated by hand, was intact and undamaged.

Vacuum Pump The vacuum pump could not be rotated by hand and the unit was intact.

Note: - Details which pertains to manufacturers, serial numbers, work orders and other specifics of individual components available in TCM 

reports.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 58

2.10.4 Right Engine Serial Number 290209 Analysis

The engine exhibited impact damage. There was no evidence of pre-impact abnormalities. The maintenance 

history of the engine was unknown, permanent maintenance records documenting scheduled and unscheduled maintenance were 

not located. 

Component Observation

External inspection 

of engine

The engine exhibited impact damage, concentrated at the bottom components of the engine. 

The right-hand accessory drive and had been fractured from the crankcase accessory 

section.

Exhaust System Condition: The exhaust system components that were received exhibited impact damage.

Starter The starter rotated by hand and exhibited corrosion

Starter Adapter

The starter adapter could not be rotated by hand. The assembly was intact and the 

scavenge pump gears and housing were intact and undamaged. The crankshaft to camshaft 

timing was verified by the alignment of the gear‟s timing marks.

Ignition Harness All leads were frayed or damaged shielding and had been cut from the mounting covers.

L/H Magneto

The left-hand magneto turned freely by hand. The magneto was installed and tested on the 

test bench and produced a blue spark across a 7 mm gap through the full range of test bench 

RPM. 05-13-08 overhaul date.

R/H Magneto

The right-hand magneto turned freely by hand. The magneto was installed and tested on the 

test bench and produced a blue spark across a 7 mm gap through the full range of test bench 

RPM. 05-13-08 overhaul date.

Oil Cooler The oil cooler exhibited impact damage. Drake air overhaul. Additional numbers: 428326, 

01-27-06

Oil Pump

The oil pump drive was intact. The oil pump cavity contained light scratches and exhibited 

normal operating signatures. The oil pump gear teeth exhibited normal operating 

signatures. The oil pressure relief valve and seat contained no obstructions and exhibited 

signatures of proper seating.

Oil Filter

The oil filter housing was cut open using the Champion cutting tool and the filter element 

was cut from the canister to allow examination. The oil filter element was examined and 

contained an insignificant amount of material.

Throttle and Fuel 

Control Assembly

The unit exhibits corrosion and the levers were immovable by hand. Finger screen 

removed and material was present. The unit was disassembled and there was corrosion 

present. The internal components were found to be intact and seating properly. The 

passages where open and unrestricted.

Fuel Pump

The fuel pump could not be turned through by hand. The fuel pump drive was fractured by 

turning the engine through prior to removing the fuel pump. The fuel pump was 

disassembled to examine the internal components. The internal components were intact 

and exhibited corrosion damage.

Fuel Manifold Valve

The fuel manifold valve exhibited impact and corrosion damage. The cover was breached. 

The manifold valve was disassembled to examine the internal components. The manifold 

valve plunger assembly was intact, secure and undamaged. There were no signatures of 

fuel stains or leakage in the vent chamber side of the diaphragm.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 59

Component Observation

Fuel Nozzles and 

Lines

The fuel nozzles were restricted. All nozzles exhibited various degrees of distortion. The 

number 5 nozzle was fractured through at the large threaded (cylinder) end. All fuel nozzle 

lines exhibited impact damage. The numbers 2, 4, 1 and 5 fuel lines were exhibited nozzle 

nut separation.

Spark Plugs

The sparkplugs contained corrosion and had normal wear signatures in accordance with the 

Champion aviation check-a-plug comparison chart. The 5B spark plug was undisturbed 

from the cylinder but was intact.

Alternator The alternator could not be turned through by hand and exhibited impact and corrosion 

damage. The drive coupling was intact.

Oil Sump

Condition: The oil sump drain plug was not safe tied. The oil sump exhibited impact 

damage and was crushed. The oil sump was drained of oil and the amount was residual. 

The oil was dark in color and contained earth.

Oil Pick-up Tube & 

Screen

Condition: The oil pick-up tube exhibited impact damage. The oil suction screen was 

unrestricted.

Induction System The induction risers and balance tube exhibited impact damage and corrosion.

Cylinder #1 

Cylinder #2

Cylinder #3 

Cylinder #4

Cylinder #5

Cylinder #6

The spot putty was not evident on the cylinder hold-down nuts. The cylinder combustion 

chamber had a normal amount of combustion deposits and the bore condition was free of 

scoring and undamaged. The cylinder skirt was intact and undamaged and there were no 

hone marks visible in the cylinder bore ring travel area. The intake and exhaust valve heads 

exhibited normal deposits and operating signatures. The rocker box area had an oil residue 

indicating lubrication to the overhead. The cylinder overhead components (valves, rocker 

arms, guides, springs, retainers and shafts) were lubricated and undamaged.

No. 1, 2, 3, 4, 5, & 

6 Piston, Rings and 

Pin

The piston head exhibited a normal amount of combustion deposits. These deposits had an 

appearance of exposure to moisture. The piston skirt was free of scoring and damage. The 

piston rings were intact, free in their grooves, exhibited normal wear and operating 

signatures. The piston pin and plug assembly was intact and undamaged.

Lifter

Intake & Exhaust

The lifter faces were undamaged and exhibited normal operating signatures. The lifter 

bodies were undamaged and exhibited normal operating signatures.

Crankshaft

The crankshaft and counterweight assembly was intact. The connecting rod journals, main 

journals and thrust surfaces were undamaged and showed no signs of abnormal wear or 

lubrication distress. The crankshaft counterweight pins, plates and snap-rings were intact. 

The counterweights were undamaged and had free and unrestricted movement on the 

hanger blades. The gear bolts were tight and safe tied and the gear teeth were undamaged. 

The oil transfer passages were open and unrestricted. Alternator drive face gear teeth were 

intact and undamaged. The oil transfer collar was intact and undamaged. The oil transfer 

plug was tight and in position.

Component Observation

#1 Main Bearings

The #1 (rear) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

#2 Main Bearings

The #2 (intermediate) crankshaft main bearings exhibited fretting at their mating surfaces. 

The bearings were intact and exhibited an insignificant amount of contamination and hard 

particle passage. There were no signs of lubrication distress.

#3 Main Bearings

The #3 (intermediate) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

#4 Main Bearings

The #4 (intermediate) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 60

#5 Main Bearings

The #5 (front) crankshaft main bearings exhibited normal operating and lubrication 

signatures. The bearings were intact and exhibited an insignificant amount of 

contamination and hard particle passage. There were no signs of lubrication distress.

No. 1, 2, 3, 4, 5 & 6 

Connecting Rod

The connecting rod assembly was intact and undamaged. The connecting rod nuts and 

bolts were intact and secure. The connecting rod bushing exhibited normal operating and 

lubrication signatures.

No. 1, 2, 3, 4, 5 & 6 

Connecting Rod 

Bearings

The connecting rod bearing exhibited normal operating and lubrication signatures. The 

connecting rod bearings were intact and exhibited an insignificant amount of contamination 

and hard particle passage. There were no signs of lubrication distress.

Camshaft

The camshaft lobes exhibited normal operating signatures. The camshaft gear was intact 

and exhibited normal operating signatures. The gear bolts were tight and safe tied and the 

gear teeth were undamaged. W/O# RA6732-1

Crankcase

The crankcase was intact. The cylinder bays were intact and undamaged. The numbers 2, 3 

and 4 main bearing support lower mating surfaces exhibited rough surfaces from fretting. 

The remaining main bearing support mating surfaces were intact and exhibited no signs of 

fretting. There were no signs of bearing tang lock-slot elongation. The main bearing 

support diameters were intact. The oil galleys and passages in the left and right crankcase 

halves were intact, clear and unrestricted.

Accessory Gears

The accessory gears had continuity. The teeth were undamaged and exhibited normal 

operating signatures. The right-hand accessory drive gear was not returned with the 

engine.

Component Observation

Turbocharger

The turbocharger could not be rotated by hand. The turbine housing was received 

separated from the main assembly. The housing intact and there was no cracks or exhaust 

leak signatures present. The turbine blades were intact. The center housing oil inlet and 

outlet fittings were intact and there were no signatures of oil leakage. The center housing 

was intact and there were no cracks or exhaust leaks present. The compressor housing was 

intact and there were no cracks present. The compressor housing was attached securely to 

the center housing. The compressor blades were intact and they exhibited minimal erosion 

signatures. Debris was present in the compressor wheel.

Controller The controller exhibits corrosion and the lever was immovable by hand. The lever was 

intact and secure.

Overboost Valve The overboost valve exhibited impact damage.

Wastegate The wastegate (exhaust by-pass) valve was in the full open position and the linkage was 

intact. The wastegate and actuator assembly was intact and undamaged.

Propeller Governor The propeller governor could be rotated by hand. The lever assembly from fractured from 

the unit.

Vacuum Pump The vacuum pump could not be rotated by hand and the drive was fractured from the 

assembly.

Note: - Details which pertains to manufacturers, serial numbers, work orders and other specifics of individual components available in TCM 

reports.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 61

2.11 Training and testing for pilots of light piston engine aircraft

2.11.1 The forced landing option

If, instead of attempting to return to the airport, the pilot had decided to force land into the lake more or less 

straight ahead, the outcome might have been different. There would still have been a crash risk and probably a 

rapid longitudinal deceleration, but the vertical speed at impact could have been low, the wings could have been 

leveled and this would have made the end of the flight far more survivable for all on board.

Piloting skills and decisions are principally the products of training and experience. Height loss is always 

increased in a gliding turn; and the consequences of a mishandled turn-back are often fatal. An experienced pilot 

who habitually flew single-engine light aircraft would be more likely to force land than to turn back because he or 

she generally knows that there is seldom another realistic option. On the other hand, pilots who habitually fly 

twin-engine light aircraft seldom, if ever, train for a forced landing, even though there may be a written procedure 

for that eventuality. 

2.11.2 The pilot’s decision to return

The pilot had considerable experience in light twin engine aircraft. He had acquired more than 12,000 hours and 

more specifically, more than 10,000 hours in the 402C aircraft. Consequently, it is possible that the pilot never 

considered the forced landing option when the aircraft would no longer climb. What seems likely is that under 

extreme pressure, he maintained the only option that occurred to him – returning to the airport. That was certainly 

his expressed intention when he declared to ATC that he would be returning and would accept runway 27 after 

notified about the white smoke trailing behind his left engine. At that stage the aircraft was probably still climbing 

or at least in level flight, and so it was a reasonable decision at the time it was uttered. 

Circumstances changed when it was apparent that the aircraft would no longer climb and that might explain why 

the pilot secured the right engine. If he thought that the failure was of the right engine, and not the left that was 

reported as smoking, he probably knew that unless he feathered the propeller and secured the engine, he had no 

hope of returning to the airport.

As a result of the decision to accept runway 27 the following tasks, which are standard procedure for any 

commercial pilot were not accomplished;

 Under no circumstance should you try and return to the runway just departed until a safe altitude has been 

attained, the situation has been assessed, and the aircraft can make it back safely.

 Always climb to a safe altitude before any actions are taken. If unable to climb, or turn due to obstacles 

(building, trees, hills/mountains, towers etc.) standard procedures are to select a location straight ahead 

(free of obstacles, if possible) and land while still under control.

 Under no circumstance should the gear or flaps be extended until it is certain the field can be made.

 Under no circumstance should a turn be made into the engine with a suspected discrepancy.

The evidence of the hurried nature of the tasks performed and the inadequate review of critical information 

between the time of the pilot‟s acceptance of the offer to land on runway 27 and the flight making a turn to 

attempt the landing on runway 27 indicates that insufficient time was available to fully or effectively carry out 

these actions. According to eyewitnesses‟ reports, the aircraft was about 150 to 300 feet when it initiated a sharp 

left turn while trying to intercept runway 27 and extended gear while in the turn. Immediately after gear extension 

the aircraft could no longer maintain altitude, stalled, became inverted and started a nose dive toward terrain 

(lake). Consequently, the above necessary steps were performed improperly or not at all and the pilot failed to 

recognize that the airplane was heading toward terrain. The evidence indicates that the pilot committed a series of 

operational errors that led to the accident. The errors, which individually were not causal, interacted in a way that 

caused the accident.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 62

Researchers studying decision making in dynamic situations32 have suggested that experienced persons can 

quickly make decisions based on cues that they match with those from previous experiences encountered in 

similar situations. A referenced text refers to this characteristic as Recognition Primed Decision Making, in 

which a decision maker‟s rapid assessment of the situation is almost immediately followed by the selection of an 

outcome. 

It states:

Our research has shown that recognitional decision making is more likely when the decision 

maker is experienced, when time pressure is greater, and when conditions are less stable.33

It is likely therefore that when previously faced with similar situations such as the opportunity to return for a 

landing after having experienced some sort of failure or problems previously, the pilot who had acquired more 

than 12,000 hours in total and more specifically more than 10,000 hours in this make and model airplane, 

accepted the offer and landed without incident. However, recognition primed decision making can present risks to 

the decision maker if the initial assessment of the situation is incorrect, or if the situation changes sufficiently 

after the decision has been made but the initial decision is not reconsidered. In this accident, the latter scenario 

appears to have been the case; there is no evidence that the pilot reconsidered the initial decision to accept the 

offer to land on runway 27 versus continuing the climb to a safe altitude and assessing his options and all 

subsequent actions were directed to completing the steps necessary to successfully land.

The evidence suggests that either of two reasons could account for the pilot‟s persistence in attempting to land 

rather than climb to a safe altitude and assess his situation. These include the failure to adequately consider the 

time required to perform the steps needed to climb to a safe altitude, assess his situation, select a suitable runway 

and return for a landing, considering the report of white smoke trailing behind his engine and the reluctance of 

decision makers in general to alter a decision once it has been made. By not reconsidering that initial decision, 

the pilot acted consistently with the findings of human factors research on decision making that found that 

decision makers are reluctant to alter a decision after it has been made. For example:34

Operators tend to seek (and therefore find) information that confirms the chosen hypothesis and to avoid 

information or tests whose outcome... could disconfirm it. This bias produces a sort of “cognitive tunnel 

vision” in which operators fail to encode or process information that is contradictory to or inconsistent 

with the initially formulated hypothesis. Such tunneling seems to be enhanced particularly under 

conditions of high stress and workload.

Thus, in addition to simply being too busy to recognize that he could not properly and safely return to a landing 

on runway 27 given his altitude, weight and configuration, once the decision to land on runway 27 had been 

made, the course of action taken was to continue the approach rather than to discontinue it.

2.11.3 Engine failure training and testing in light twin engine aircraft

A glide landing in a twin-engine aircraft is not generally contemplated except just after take-off when the landing 

gear is down and there is runway remaining. All other engine failure procedures are predicated on correctly 

identifying the failed engine; securing it; climbing away if necessary; and flying a single-engine approach and 

landing to a runway. This emphasis is also reflected in the routine recurrent testing of pilot skills. 

 

32 Klein, G., (1993) Naturalistic Decision Making: Implications for Design. Wright-Patterson Air Force base, Ohio Crew System 

Ergonomics Information Analysis Center.

33 Klein, G., (1993) A recognition primed decision (RPD) model of rapid decision making. In Klein, G., A., Orasanu, J., Calderwood, R., 

and Zsambok, C.E., (Eds), Decision Making in action: Models and Methods. Norwood, New Jersey, Ablex, p. 146.

34 Wickens, C. D., (1984) Engineering Psychology and Human Performance. Columbus Ohio: Charles E. Merrill, p. 97.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 63

2.12 The Implications of Performance Category C

An engine failure after take-off in a twin-engine Performance Group C aircraft requires immediate, prioritized and 

accurate corrective action from the handling pilot. This is because:

1. Many Group C aircraft will not sustain a single engine climb at maximum take-off weight unless the landing 

gear and flaps are retracted. Consequently, there may be a period between leaving the runway and achieving 

a suitable climb speed and configuration when, if an engine fails completely, the only realistic option is to 

force land immediately.

2. Some Group C aircraft require the pilot to feather the propeller of a failing engine immediately because if the 

propeller RPM decay below a certain level, it may be impossible to feather the propeller35. (See Appendix 

5.16)

3. An unexpected and complete engine failure results in one propeller very rapidly changing its state from thrust 

to drag. The result is a reduction in forward thrust of significantly more than 50%. The sudden change tends 

to cause a loss in airspeed whilst the pilot recognizes the failure and takes early corrective action.

4. Until the propeller of the failed engine is feathered, a Group C aircraft at or near maximum take-off weight 

may be unable to accelerate in level flight or to climb.

5. The single-engine rate of climb is highly dependent on airspeed. If, after an unexpected engine failure, the 

airspeed has reduced below the „blue line‟ optimum marked on the Air Speed Indicator (ASI), the aircraft 

may not climb despite it being properly configured.

Consequently, the handling skills required to successfully overcome an unexpected failure shortly after take-off in 

a twin-engine aircraft of Performance Category C are among the most demanding of the skills required by any 

airplane pilot. He or she must take immediate action to contain the situation and decide rapidly, based on a 

number of critical factors, whether to force land or to climb away from the point of failure.

2.13 ATC Tower Controller

The Air Traffic Controllers that handled the accident aircraft were all Grade One Air Traffic Control Officers and 

were properly trained and provided appropriate air traffic services. In addition, the investigation examined the 

actions of the ATC Tower controller to determine what role, if any, his actions may have had upon the accident. 

By the standards of the FAA, CAA and ICAO the pilot and not the controller was in the best position to determine 

the safety of the acceptance of that offer.

2.14 Survivability

The investigation also assessed survivability issues to determine the extent to which the number of fatal injuries 

could have been reduced and the effectiveness of the seatbelt in use. Based on the extent of the damages sustained 

the accident was not survivable. The emergency response for this accident was timely and effective. The accident 

was not survivable for the airplane occupants because they were subjected to impact forces that exceeded the 

limits of human tolerances. 

2.14.1 Aircraft Seating

The analyses of the impact injuries suffered by the fatalities within the aircraft were found to be consistent with 

the cabin damage inflicted by the initial impact with the shallow water of the lake and subsequent secondary 

 

35 See Aeronautical Information Circular 100/2005 Propeller Feathering on Twin Piston Engined Aircraft Appendix 5.16
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 64

cartwheel motion of the aircraft hitting the lake bottom. Most of these impact injuries were chest injuries, injuries 

to the ankles and leg and feet and there were some head injuries. There is clear evidence that chest injuries were 

compounded by the separation and collapse of the seats and by the limitations of the passenger seats, where only 

lap strap was available.

2.15 Situational Awareness36

Once the decision was made to accept the offer to land on runway 27, the pilot displayed poor situational 

awareness, with regard to such critical factors as the following;

 His current altitude

 Proximity to terrain

 Flight Path

 Recognition of stall speed

 Extension of landing gear while in a turn

 Excessive weight - Load Factor37

 Excessive bank angle

 Turning an aircraft into the critical (dead) engine38.

Situational awareness refers to a flight-crew‟s understanding of the status and flight-path of the aircraft and the 

accuracy of their prediction about its future status and flight path. Deficiencies in situational awareness can lead to 

potential failures involving flight-path prediction or comprehension and prediction of system parameters as in the 

case here involving C6-NLH. The accident indicated that from the beginning of his attempt to land on runway 27, 

the pilot exhibited a lack of awareness of fundamental parameters of the approach.

2.16 CAD Oversight

CAD / FSI mandate is surveillance of certified AOC as per CASR 2001 Schedule 12. As Acklins Blue Air 

Charter Limited was not an AOC holder, no surveillance by CAD/FSI was conducted. C6-NLH was a private 

aircraft owned by an individual. It was registered to Lebocruise Air Limited and operated by Acklins Blue Air 

Charter Limited. Neither of the above companies was registered with or underwent a certification process by the 

Bahamas Civil Aviation Department as required by Schedule 12 of the Bahamas Civil Aviation (Safety) 

Regulations 2001 to be authorized to conduct cargo or passenger operations as an authorized Air Operator 

Certificate holder. 

Several months prior to this accident, the Flight Standards Inspectorate went on a proactive campaign where 

information was shared with the daily newspaper and media outlets. Several articles were written and the 

department took the message to the airwaves via talk show and media houses warning the general public about the 

dangers of travelling with unauthorized air carriers. Numerous posters were strategically placed at all Fixed Base 

Operations and the General Aviation Center warning about the dangers of unauthorized air carriers.

 

36 Situational awareness has been defined as the perception of the elements in the environment within a volume of time and space, the 

comprehension of their meaning, and the projection of their status in the near future.

37 Load factor - In aeronautics, the load factor is defined as the ratio of the lift of an aircraft to its weight and represents a global measure 

of the stress. Since the load factor is the ratio of two forces, it is dimensionless. However, its units are traditionally referred to as g, because 

of the relation between load factor and apparent acceleration of gravity felt on board the aircraft. A load factor of one, or 1 g, represents 

conditions in straight and level flight, where the lift is equal to the weight. Load factors greater or less than one (or even negative) are the 

result of maneuvers or wind gusts. 

38 Critical engine – an engine whose failure would mostly affect the performance of an aircraft. In most small twin engine aircraft (unless 

they have a counter rotating engine) the left engine is considered the critical engine.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 65

The Flight Standards Inspectorate additionally engaged the assistance of the Airport Authority and NAD with 

meetings and strategic planning on ways to curb the incidence of unauthorized air charter operators. List of all 

authorized air charter operators were distributed to the media and all stake holders at MYNN. Post accident, the 

message was again presented to the television media outlets and print media for their assistance with spreading 

the message about the dangers of travel with unauthorized air carriers.

2.17 Summary

The experienced and competent pilot was confronted with an unenviable emergency at a critical stage of flight. A 

number of potentially confusing cues may have led to him misidentifying the partial loss of power from the left 

engine and secured the right engine. His reaction and instinct to return to the runway confounded his instinctive 

reaction to an emergency situation, which is much practiced in training and testing.

The time for him to make the correct diagnosis and to take the corrective action was short. During this time he 

announced his decision to return to the airport for a landing on runway 27 and initiated a turn to the left. With the 

left engine problem persisting and the right engine secured and not producing thrust at this time, the reduced 

thrust of the left engine was insufficient to maintain lift. In a tightening turn, with gears extended, the aircraft 

stalled, became inverted which resulted in a steep nose dive into the lake.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 66

3.0 Conclusions

(a) Findings

1. Acklins Blue Air Charter was advertising and operating as a Bahamas air taxi operator without having 

undergone the certification process in contravention of Bahamas Civil Aviation (Safety) Regulations 

Schedule 12.

2. The airplane was issued a Certificate of Airworthiness on May 19, 2010, by the Bahamas Flight 

Standards Inspectorate, and was being operated by Acklins Blue Air Charter. 

3. The Cessna 402C aircraft is classified in the performance Group C. This requires rapid feathering of the 

propeller of a failed engine and the raising of flap and the landing gear in order to achieve maximum 

climb performance.

4. The airplane maintenance records were not located; therefore, no determination could be made whether 

the airplane was being maintained in accordance with Bahamas Civil Aviation Regulations.

5. The 12,000 hour pilot and second pilot were not qualified to operate in Bahamas commercial air taxi 

operations. 

6. No determination could be made whether the pilot or second pilot had completed required training and 

had accomplished a satisfactory recurrent flight check of their flying ability as required by CASR 

Schedule 12 and 14 for aircraft operating in commercial air transportation as well as the stipulation by the 

insurance policy.

7. Post-accident weight and balance calculations indicate the airplane was being operated approximately 523 

pounds over maximum certificated takeoff weight (6,850 lb)

8. The pilot was advised by an air traffic controller that white smoke was trailing the left engine during 

takeoff; the pilot did not declare an emergency or advise the controller of any engine failure or 

mechanical abnormality.

9. The airplane‟s left engine could not produce rated shaft horsepower during takeoff.

10. Several factors contributing to the degradation of the airplane‟s performance and its inability to maintain 

flight include the wind-milling propeller, the pilot‟s intentional initiation of a steep turn to return to the 

departure airport, and his intentional lowering of the landing gear during the turn to return.

11. While turning to return, the airplane stalled, pitched nose down, and impacted in a lake.

12. The search and rescue efforts were timely and appropriate; however, the lack of accurate information on 

the pilot submitted flight plan delayed recovery of all victims.

13. The left propeller was not feathered.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 67

14. The No. 2 cylinder of the left engine failed due to fatigue that originated in the root of the cylinder head 

thread that was engaged with the first thread on the barrel.

15. Post-accident inspection of the cockpit revealed several switches for the right engine were secured; 

however, no determination could be made when the switches were placed / moved in those positions.

16. No evidence of failure of the airplane‟s structures or flight control system contributed to the accident.

17. Existing regulations did not require the aircraft to be fitted with flight recorders. The lack of any recorded 

data about the aircraft‟s performance or the flight crew conversations deprived the investigation team of 

essential factual information.

18. Current Civil Aviation Department personnel and budget resources may not be sufficient to ensure that 

the quality of surveillance for certified as well as uncertified air carrier operations will improve.

19. Airside access procedures are inadequate at Fixed Base Operators. Access to the secure airside occurring 

without any check of individuals to challenge whether they have a legitimate reason for accessing the 

secure airside. FBO door to access airside is not secured or locked continuously; persons observed 

walking in and out without being challenged.

20. Flight Plan Forms are being accepted and transmitted to ATC with incomplete information. This 

information is vital for search and rescue purposes.

21. Weather was not a factor in the accident.

22. ATC was not a factor in the accident.

23. Currently flight plans for private flights are only required for international operations.

24. The pilot was aware of discrepancy associated with the manifold pressure reading of the left engine prior 

to takeoff. This discrepancy was brought to his attention by a client from the flight immediately preceding 

the accident flight.

25. The exact center of gravity of the accident airplane could not be calculated accurately as no indication of 

what seat each passenger occupied in the airplane and no indication of where luggage or equipment were 

placed on the aircraft could be determined. However, due to the exceedance of weight limits the aircraft 

was already outside the allowable center of gravity envelope developed by the manufacturer.

26. The pilot had insufficient time to prepare for the approach to runway 27 before beginning the approach. 

The airplane pitched up quickly into a stall, after extension of gear, recovery before ground impact was 

unlikely once the stall began. 

27. Post accident inspection did not reveal any mechanical evidence or problems with the right hand engine.

28. The pilot‟s decision to return to the airfield was reasonable. Once the aircraft began to lose height a 

return to the airfield became impractical and a forced landing in the direction of flight should have been 

attempted.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 68

29. The right propeller was never recovered from the lake.

(b) Causal Factors

1. The left engine suffered a mechanical failure of the #2 cylinder, and therefore could not produce rated 

shaft horsepower. No indication of total loss of power with the left engine reported. 

2. Right Engine electrical and engine control switches were found in the “OFF” position, therefore the 

aircraft was incapable of climbing on the power of one engine alone.

3. The excess weight above the maximum weight allowed for takeoff may have been an important factor in 

the aircraft‟s inability to gain adequate altitude after takeoff. 

4. The pilot secured the right engine which was mechanically capable of producing power resulting in a total 

loss of thrust. He then sometime thereafter initiated a steep turn with gear down and the left engine 

already not developing sufficient shaft horsepower to sustain lift.

5. The pilot attempted to return to the departure airfield but lost control of the aircraft during a turn to the 

left.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 69

4.0 Recommendations:

As a result of this investigation, the AAIPU makes the following recommendations to the Department of Civil 

Aviation:

1. Evaluate the surveillance programs to ensure that budget and personnel resources are sufficient and used 

effectively to maintain adequate oversight of the operation and maintenance of both certified and uncertified 

air carriers, irrespective of size.

2. Request that the Government of the Bahamas enact legislation that creates tougher penalties for persons 

engaging in unauthorized air charters.

3. Request that Civil Aviation Department amend regulations to enforce that flight plans be required for all 

flights, private and commercial, domestic and international and that the AIP be amended to show this 

requirement.

4. Request the Civil Aviation Department in coordination with Air Traffic Control institute policies and 

procedures where aircraft are not allowed or given permission to turn in any direction after takeoff prior to 

attaining a minimum of 500 feet as is standard practice in pilot training.

5. Request that the Civil Aviation Department amend its information gathering forms to capture vital 

information that may be required in the event of lost or unavailable historical information for Bahamas 

registered aircraft.**39

6. Request that the Civil Aviation Department in conjunction with NAD require that appropriate and certified 

weighing devices be installed at all points where aircraft are dispatched so that pilots may have a means to 

accurately weigh all occupants and cargo that are to be loaded onto aircraft prepared for flight.

7. Request that the Civil Aviation Department enact regulations that make it mandatory that all pilots of private 

aircraft be required to complete an accurate load and weight and balance document which must be left with an 

agent at facilities where they depart.

8. Request that the Civil Aviation Department institute policies whereby Aviation Medical Examiners can issue

pilots medical certificate immediately upon satisfactory examination as the current policy causes delays in 

issuing medical certificates. This delay from examination to processing and issuance results in pilots taking a 

chance and flying without a medical certificate which invariably renders their pilot licenses invalid.

9. Request that the Civil Aviation Department amend regulations to require all private pilots to have a 

proficiency check or bi-annual flight review every 2 years prior to renewal of their private pilot license.

10. Request ATC to review all Flight Plan Form filing procedures to ensure all required information is gathered 

as it is vital for search and rescue purposes.

11. Request Airport Authority put in place tighter security measures to properly account for all persons gaining 

access to the secure airside.*

40

 

39 **Prior to the publication of this report, the Flight Standards Inspectorate instituted corrective action and developed an application form 

that captures missing information that can establish a baseline of historical aircraft information.

40* Prior to the publication of this report, corrective actions as a result of recommendation 5 – 9 and 11 above have been addressed by 

stakeholders and relevant authorities.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 70

12. Request Airport Authority explore a surveillance program or require all Fixed Base Operators to install 

surveillance equipment (CCTV) to cover all areas under their control* to properly capture all activities by 

persons gaining access to the secure airside at all Fixed Base Operators (FBO).*

13. Request Airport Authority to coordinate with all Fixed Base Operators to develop a safety and security plan 

and train their personnel with secure airport access procedures.*

14. Request Airport Authority to coordinate with all FBO to install a secure system (door locking system with 

buzzer) whereby persons do not have unlimited and unimpeded access to the secure airside without the 

knowledge of representatives of the facility.*

15. Request all FBO‟s to ensure all information is included on flight plan form prior to transmitting it to ATC 

including all passenger information (item 22 on Flight Plan Form). This information is vital for search and 

rescue purposes.*
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 71

5.0 APPENDICES:

Appendix 5.1 Cylinder Factual Report (NTSB)

REPORT NOT INCLUDED HERE BUT MAY BE SUPPLIED IF 

REQUESTED
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 72

Appendix 5.2 Left and Right Engine Factual Report (TCM)

REPORT NOT INCLUDED HERE BUT MAY BE SUPPLIED IF 

REQUESTED
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 73

Appendix 5.3 Acklins Blue Companies

Appendix 5.4 Acklins Blue Air Charter
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 74

Appendix 5.5 Acklins Blue Air Charter
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 75

Appendix 5.6 ATC tower transcript

REPORT NOT INCLUDED HERE BUT MAY BE SUPPLIED IF 

REQUESTED
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 76

Appendix 5.7 Flight Plan Form

FLIGHT PLAN NASSAU TO SAN SALVADOR

FLIGHT PLAN NASSAU TO TREASURE CAY, ABACO BAHAMAS
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 77

Appendix 5.8 Fuel Uplift Slip
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 78

Appendix 5.9 Alert Issued

Alert

Alert # SA/A10-01312/001/10-9-10

To: Mrs. Deborah Coleby

Director of Operations

Nassau Airport Development Company

Captain Patrick Rolle

Director 

Civil Aviation Department

Mr. Milo B. Butler III

General Manager

Airport Authority 

Mr. Joseph Albury

Deputy Director

Air Traffic Control 

Mr. Alphonzo Bowe

Managing Director

Executive Flight Support

Mr. Anthony Hinsey

Public Relations Manager

Odyssey Aviation

Re: Flight Plan Form Completion and Airside Security and Accountability.

In Accordance with ICAO Annex 13, Ninth Edition, July 2001, Chapter 6 Paragraph 6.8 Safety 

recommendations

“ At any stage of the investigation of an accident or incident, the accident or incident investigation 

authority of the State conducting the investigation shall recommend to the appropriate authorities, 

including those in other States, any preventive action that it considers necessary to be taken promptly 

to enhance aviation safety.”

In light of ongoing accident investigations the following Alert is being advanced in an effort to ensure 

safety, security and enhance search and rescue procedures.

The following findings and observations have been made and must be addressed by the relevant 

authority and stakeholders immediately:

1. Pilots or their agents are not completing flight plan forms in its entirety as required by Flight 

Plan Form Document. Though provided on the flight plan forms, accepting agents are not 

ensuring pilots or those acting on their behalf, list the correct passenger count.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 79

2. Flight Plan Form in use by NAD only requires that items 1 thru 20 be completed in order for 

form to be processed.

3. Agents are transmitting incomplete flight plan forms to ATC. 

4. ATC is accepting, processing and issuing ATC services to pilots based on incomplete flight plan 

forms.

5. While conducting investigations at an FBO the investigation team observed individuals who 

were given unimpeded access to the secure airside without being challenged, recorded or 

documented. 

Note: Individuals were allowed to access the secure airside; board an aircraft yet no one at 

the facility knew who they were or how many people left through their facility or what 

aircraft they boarded.

The following recommendations are hereby advanced:

1. Policy and Procedures should be developed, enhanced or enforced by relevant agency to ensure 

all information required by Flight Plan Form is captured by said form.

2. In light of the accident involving C6-NLH, NAD should amend this form to include items 1 thru 

22 as being required prior to processing of form for all general aviation aircraft. This information 

would prove to be invaluable as search and rescue procedures can be enhanced as well as 

notification of next of kin can be made easier.

3. Training should be developed, initiated or enhanced with the entities responsible for accepting 

and dispensing of such information to Air Traffic Control to ensure that all information required 

is captured.

4. All entities involved should develop policy, procedures and institute training to its staff on 

methods to reject such Flight Plan Forms if required information are not completed.

5. Airport Authority as the unit with responsibility for security should ensure that all stakeholders 

especially in the General Aviation and Fixed Base Operations Area provide an acceptable 

security plan that would ensure tighter security measures and more accountability of persons that 

grant access to the secure airside.

6. As part of this approved security plan procedures should be in place for the continued monitoring 

and surveillance of the ramp used by General Aviation and all Fixed Base Operators (Suggestion 

CCTV).

7. Stakeholders should be made to develop policy, procedures and provide training to its staff on 

airside safety and security responsibilities and put stricter airside access criteria in place.

This department requests that all relevant entities institute the above recommendations with immediate 

effect in order to enhance safety, security and search and rescue operations.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 80

Appendix 5.10 Engine Failure after Take-off Checklist
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 81

Appendix 5.11 Crash Aircraft Diagram

Appendix 5.12 Reference Aircraft Diagram
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 82

Appendix 5.13 CASR Regulation Part X, Regulation 67.

Appendix 5.14 CASR Regulation Part X, Regulation 68
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 83

Appendix 5.15 Aerodrome Chart Nassau, Bahamas
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 84

Appendix 5.16 Aeronautical Information Circular 100/2005

Propeller Feathering on Twin Piston Engine Aircraft
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 85

Appendix 5.17 Cessna 402C Dual Manifold Pressure Gauge

Manifold vacuum / pressure - an effect of a piston's movement on the induction stroke and the choked flow through a throttle in the intake 

manifold of an engine. It is a measure of the amount of restriction of airflow through the engine, and hence of the unused power capacity in 

the engine.

The rate of airflow through an internal combustion 

engine is an important factor determining the amount of 

power the engine generates. Most gasoline engines are 

controlled by limiting that flow with a throttle that 

restricts intake airflow. Manifold vacuum is present in 

all naturally-aspirated engines that use throttles 

(including carbureted and fuel injected gasoline engines

using the otto cycle or the two-stroke cycle).

The mass flow through the engine is determined by the 

rotation rate of the engine, multiplied by the 

displacement of the engine, and the density of the intake 

stream in the intake manifold. In most applications the 

rotation rate is set by the application. The displacement 

is dependent on the engine geometry, which is generally 

not adjustable while the engine is in use (although a 

handful of models do have this feature, see variable 

displacement). 

Restricting the input flow reduces the density (and 

hence pressure) in the intake manifold, reducing the 

amount of power that is produced. It is also a major 

source of engine drag, as the engine must pump material 

from the low-pressure intake manifold into the exhaust 

manifold (at ambient atmospheric pressure).

When the throttle is opened (in a car, the accelerator pedal is depressed), ambient air is free to fill the intake manifold, increasing the 

pressure (filling the vacuum). A carburetor or fuel injection system adds fuel to the airflow in the correct proportion, providing energy to 

the engine. When the throttle is opened all the way, the engine's air induction system is exposed to full atmospheric pressure, and maximum 

airflow through the engine is achieved. In a "naturally-aspirated" engine, total engine output is thus determined by the ambient barometric 

pressure. Superchargers and turbochargers can "boost" manifold pressure to above atmospheric pressure.
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 86

Appendix 5.18 Alert SA/A10-01312/002/10-9-10 Historical Information
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 87
Air Accident Investigation and Prevention Unit 

Final Report C6-NLH Page 88

Appendix 5.19 CRASH SITE DIAGRAM