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NTSB investigation record

ANC18FA022

Completed

Beech 35A33· N9378Y

Date
January 30, 2018
Location
Helenwood, TN
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's mismanagement of the available fuel, which resulted in a total loss of engine power due to fuel starvation. Contributing to the accident was the pilot's failure to follow the air start checklist.

Investigator assessment

Analysis narrative

The private pilot and passenger were conducting a cross-country personal flight. About 1 hour 35 minutes after departing from an intermediary fuel stop, while in level cruise flight about 6,800 ft GPS altitude, the engine lost all power. The pilot stated that the engine gauges did not indicate any sign of overheating or other mechanical problems. He followed the emergency checklist and attempted to restart the engine without success. He subsequently broadcast a "mayday" call three times on the 121.5-MHz frequency but received no response. He attempted to glide the airplane to the nearest airport, but when he realized the airplane could not reach the airport, he conducted an emergency landing to a logging road in mountainous terrain, which resulted in substantial damage to wings and fuselage. Postaccident examination of the airplane revealed that the left auxiliary fuel tank was intact but empty. The left main fuel tank was intact, and between about 5 to 7 gallons of fuel were recovered from the left main fuel tank. The fuel pickup was separated at the wing root due to impact damage. Both the right auxiliary and right main fuel tanks were breached. About 7 to 10 gallons of fuel were recovered from the right main wing fuel tank. No fuel was present in the right auxiliary fuel tank. The electric auxiliary fuel pump switch was found in the "ON" position, and the fuel selector valve was found in the "AUX TANK" position, which was not the correct position for the air start procedure outlined in the Pilot Operating Handbook and FAA Approved Flight Manual.  No fuel was present in either the fuel inlet line or the fuel return line. The fuel line between the fuel metering unit and the fuel manifold valve was removed at the throttle body, and about a teaspoon of fuel was recovered. Postaccident examination of the airframe and engine and an engine test-run revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.  Given the lack of fuel in the fuel lines forward of the engine firewall; the fuel present in the main fuel cells; and no evidence of any preimpact mechanical malfunctions or failures with the airframe, engine, or its systems, it is likely that the pilot mismanaged the available fuel, which resulted in a total loss of engine power due to fuel starvation.  In addition, given that the fuel selector was found in the "AUX TANK" position, it is likely that the pilot did not follow the approved air start procedure in the Pilot Operating Handbook and FAA Approved Airplane Flight Manual.

Source record

Factual narrative

HISTORY OF FLIGHT On January 30, 2018, about 1345 eastern standard time, a Beech 35-A33 airplane, N9378Y, sustained substantial damage during a forced landing following a total loss of engine power near Helenwood, Tennessee. The private pilot sustained serious injuries, and the passenger sustained fatal injuries. The airplane was registered to the pilot who was operating the airplane as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed near the accident site, and no flight plan was filed for the cross-country flight. The airplane departed from Venice, Florida, about 0748 destined for Urbana, Ohio, with a planned intermediate fuel stop. A Garmin GPS unit was found at the wreckage location. A review of the unit's data logs revealed that, after departing Venice, the airplane landed at Barrow County Airport (WDR), Winder, Georgia, at 1146:45 (about 4 hours later), and then departed for Urbana at 1205:30. After departure, the airplane proceeded northeast before turning north at a cruising GPS altitude that varied between about 8,291 and 6,558 ft. According to the pilot, prior to departing WDR the airplane was refueled and departed with 70 gallons of fuel onboard. After departure, while in level cruise flight, the engine "sputtered," followed by a total loss of engine power. The pilot stated that the engine gauges did not indicate any sign of overheating or other mechanical problems. He followed the emergency engine restart checklist in an attempt to restart the engine to no avail. He broadcast a "mayday" call three times on the 121.5-megahertz (MHz) frequency but received no response. He then attempted to glide the airplane to the nearest airport, but he realized the airplane could not reach it, so he conducted an emergency landing to a logging road in mountainous terrain. The last fully recorded in-flight data point was at 1345:22 when the airplane was at a GPS altitude of 2,418 ft and 74 knots ground speed. When the airplane failed to arrive at the destination airport on time, a family member contacted local law enforcement, and they initiated a search for the missing airplane. The Federal Aviation Administration (FAA) issued an alert notice at 2003, and extensive search operations were initiated. Search operations were conducted by personnel from the Tennessee Wing of the Civil Air Patrol, Scott County Sheriff's Office, Scott County Rescue Squad, the U.S. Department of Agriculture, and multiple local fire departments. A 121.5-MHz emergency locater transmitter (ELT) signal was received in the early morning hours of January 31. Initially search personnel were unable to locate the airplane due to dark night conditions; however, about 0956, search personnel located the wreckage, and found that the passenger had died. PERSONNEL INFORMATION The pilot held a private pilot certificate with an airplane single-engine land rating. His most recent BasicMed application was on April 27, 2017. According to the pilot's logbook, as of January 25, 2018, he had accumulated 207.5 hours of total flight experience, including 150.6 hours as pilot-in-command and 14.1 hours of total flight experience in the accident airplane. AIRCRAFT INFORMATION The airplane was manufactured in 1961 and had a total time in service of 3,508.34 flight hours. The airplane was equipped with a 225-horsepower Continental Motors IO-470-J engine. At the time of the accident, the engine had accumulated 553.86 total hours since overhaul. A review of the airplane maintenance records revealed that the most recent annual inspection of the airframe and engine was completed on July 26, 2017, 33.04 hours before the accident. Shoulder Harnesses The airplane was not equipped, nor was it required to be equipped, with shoulder harnesses in any of the occupant seats. Fuel System The airplane was equipped with an optional 63-gallon usable (70-gallon total) fuel system. The system consisted of a rubber fuel cell located in each wing leading edge, which contained 22 gallons of usable fuel (25-gallon total), and was equipped with a flush-type filler cap. The system had two auxiliary fuel cells located outboard of the wheel wells in each wing. The auxiliary cells contained 9.5 gallons of usable fuel (10-gallons total). The fuel selector valve was located on the left cockpit sidewall panel, forward of the pilot's seat. The fuel selector could be selected to "OFF," the left main tank ("LH TANK"), the auxiliary tanks ("AUX TANK"), and the right main tank ("RH TANK"). Both auxiliary fuel cells were connected to a common port at the fuel selector valve so that both fed simultaneously when the fuel selector was set to "AUX TANK." The fuel injection system returned about 10 gallons of excess fuel per hour. Fuel lines were routed through the fuel selector valve to each main fuel cell. Except for the auxiliary cells, fuel was returned to the cell from which it was drawn. The auxiliary cells returned fuel to the left main cell only. According to the Pilot's Operating Handbook (POH), to provide space for the returned fuel, "the left main cell should be used to approximately half full before switching to auxiliary." Fuel Quantity Indication System Fuel quantity was measured by float-operated sensors located in each fuel cell. The sensors transmitted electrical signals to the main and auxiliary fuel quantity indicators located in the center of the instrument panel. Fuel quantity for each main or auxiliary fuel tank could be read by positioning either of the two fuel gauge selector switches which were placarded "MAIN FUEL" and "AUX FUEL", and located on the left instrument subpanel, to either right or left. METEOROLOGICAL INFORMATION The closest official weather observation station to the accident site was Scott Municipal Airport, Oneida, Tennessee, located about 5 miles northwest of the accident site. At 1353, a METAR was reporting, in part, wind, light and variable; visibility, 10 statute miles; clouds and sky condition, clear; temperature, 37°F; dew point 18°F; and an altimeter setting of 30.40 inches of mercury. WRECKAGE AND IMPACT INFORMATION The accident site was in a steep hilly area of brush- and rock-covered terrain with sparsely populated trees at an elevation of about 1,241 ft msl. A broken 25-ft-tall tree was the initial impact point. After the initial impact, the wreckage traveled northwest along a magnetic heading of about 297° for about 143 ft before coming to rest upright, left wing low, in a rock-covered gully on an approximate 321° magnetic heading. All the airplane's major components were located at the main wreckage site. The cockpit area exhibited impact damage. The engine, firewall, and instrument panel were displaced aft. The throttle was found in the near full-forward position, and the mixture and propeller were found in the full-forward position. The electric auxiliary fuel pump switch was found in the "ON" position. The fuel selector was found in the "AUX" position, and the fuel gauge selector switches were found in the main fuel – "LEFT", and auxiliary fuel – "LEFT" positions. The fuel selector valve was removed and rotated through its full range of operation. Operation was smooth without excessive play, and its detents were confirmed. The fuel selector valve sump was drained, and about 2 tablespoons of light blue fluid, consistent with 100LL fuel, were recovered. The fluid was bright, free of debris, and tested negative for water. The right auxiliary and right main fuel tank caps were on and secure. Both the right auxiliary and right main fuel tanks were breached. About 7 to 10 gallons of light blue fluid, consistent with 100LL fuel, were recovered from the right main wing tank. No fuel was present in the right auxiliary tank. Fuel was observed leaking from under the right wing. The left auxiliary and left main fuel tank caps were on and secure. The left a

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