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NTSB investigation record

ERA09FA289

Completed

Beech A36· N191MK

Date
May 15, 2009
Location
Beauregard, AL
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation.

Investigator assessment

Analysis narrative

The pilot was on the second leg of his cross-country flight, after picking up three passengers at the intermediate airport. The passengers stated that while cruising at 7,000 feet, the engine lost power. The pilot was able to restart the engine but it lost power again. The pilot rearranged the aft passengers into the aft facing seats, and then performed a forced landing to a pasture, during which the airplane collided with trees and a large rolled bale of hay. Postaccident examination of the airplane revealed the fuel selector valve was selected to the right fuel tank and the fuel drain on the selector valve was opened and there was no fuel present. The right tip tank was breached but contained about 4.5 gallons of fuel. The right main fuel tank was breached and no fuel was observed. The left main fuel tank bladder remained intact and was not leaking; approximately 1 quart of fuel was drained from the tank. The left wing tip tank was found separated from the wing; the tip tank was breached but contained approximately 1/2 gallon of fuel. No evidence of fuel leakage or browned grass was observed. Functional testing of the engine and fuel selector valve revealed no preimpact mechanical anomalies. During the functional test of the engine, the fuel supply was intentionally interrupted by turning off the test cell fuel valve and by the disconnection of the fuel pump hose supple quick-disconnect. In both cases, after engine function ceased, fuel was present in the fuel control inlet and outlet lines. Witnesses stated that prior to the accident flight; the daughter of the pilot was seen draining what was later measured to be 25.4 gallons of fuel from the main tanks. At the time when the cross-country flight started, the airplane had approximately 48.6 gallons of fuel in the main tanks and 10 gallons of fuel in each of the tip tanks. According to performance calculations made during the investigation, the engine would have burned at least 48.6 gallons of fuel at the time the engine lost power, confirming that the pilot never utilized the fuel remaining in the tip tanks.

Source record

Factual narrative

HISTORY OF FLIGHT On May 15, 2009, at 1142 central daylight time, a Beech A36, N191MK, registered to a private individual, and operated by the certificated private pilot, crashed into trees and subsequently the ground in a field in Beauregard, Alabama. The personal flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 with an instrument flight rules (IFR) flight plan filed. Visual meteorological conditions prevailed. The pilot and one passenger were killed, two passengers received minor injuries, and the airplane was substantially damaged. The flight departed Destin-Fort Walton Beach Airport (DTS), Destin, Florida, at 1041, destined for Newnan Coweta County Airport (CCO) Newnan, Georgia. According to the surviving passengers, the airplane was flying about 7,000 feet when the pilot stated that he was having engine problems. Both passengers in the back seats stated that the pilot instructed them to move forward to the aft facing seats. The female passenger moved to the seat directly behind the pilot and the male passenger moved directly behind the co-pilot’s seat and both secured their seatbelts “tightly.” They stated that the pilot attempted to restart the engine with success but it stopped again after about 30 seconds. They overheard the pilot tell air traffic control that they were going to attempt to land in a field. The passengers stated that the airplane began hitting trees and the male passenger was knocked unconscious. The female passenger believed that the male passenger was unconscious for about a minute after the airplane came to a stop. Both passengers egressed the airplane via the open cockpit area and called 911 on their cell phone. PERSONNEL INFORMATION The pilot, age 56, held a private pilot certificate with ratings for airplane single engine land and instrument airplane, issued on March 26, 1985. His latest Federal Aviation Administration (FAA) third class airman medical certificate was issued June 20, 2008, with a restriction that he must have available lenses that correct for near vision. The pilot's logbook indicated 1,618 hours of total flight time, with about 600 hours in A36 airplanes, and 40 hours in the accident airplane since it was modified with a turbo normalizing system. AIRCRAFT INFORMATION The six-seat, low-wing, retractable gear airplane, serial number (S/N) E-3362, was manufactured in 2000. The HBC Model A36 was delivered in 2000 with a Teledyne Continental Motors IO-550-B, rated at 300 horsepower (normally aspirated). On January 12, 2004, a Tornado Alley Turbo, Inc “Whirlwind System II” turbo normalizing system was installed on the airplane (STC SA5223NM and SE5222NM). On the same date, General Aviation Modification, Inc (STC SE09289SC) “turbo GAMIjectors” were installed. WEIGHT AND BALANCE INFORMATION On the day of the accident the pilot’s daughter drained about 25.4 gallons of fuel from the right and left main fuel tanks, for the trip from Newnan Coweta County Airport (CCO) Newnan, Georgia to Destin-Fort Walton Beach Airport (DTS), Destin, Florida. The airplane’s maximum gross weight was 3,650. With zero fuel on board, 340 lbs for the pilot and passenger, 25 lbs for luggage, and 13 lbs for oxygen, the airplane’s weight would have been 3,143.0 lbs. and well within the center of gravity (CG) envelope. By adding 48.5 gallons of fuel, and adding 20 gallons of fuel for the 10 gallons in each tip tank, brought the airplane’s weight to 3,554.0 lbs., with the CG still within the envelope. Had the daughter not drained the fuel from the main tanks, the airplane’s weight would have been 3,707.0 and the CG outside the CG envelope. The same calculations were performed for the return flight from DTS to CCO. The pilot and front passenger weights were 340 lbs the two aft passengers were 340 lbs, 50 lbs of baggage was added and 13 lbs for oxygen. The fuel burn from CCO to DTS estimated at 24.1 gallons the remaining fuel for the trip home would have been 24.4 with 20 lbs still in the tip tanks. The airplane’s weight at takeoff from DTS would have been 3,774.4 lbs. with the CG within the envelope. Had the pilot and daughter not drained the 25.4 gallons of fuel at CCO the airplane’s weight would have been 3,927.4 lbs., and outside the CG Envelope. METEOROLOGICAL INFORMATION A review of recorded weather data from the Auburn-Opelika Robert G. Pitts Airport, Auburn, Alabama (AUO) automated weather observation station, revealed at 1135 conditions were winds 120 degrees at 5 knots, visibility 10 statute miles, cloud condition scattered at 3,900 feet above ground level, and altimeter 30.19 inches of mercury. WRECKAGE AND IMPACT INFORMATION The main wreckage accident site was located at N032° 32 59, W085° 24 12, in a hay field located approximately 4.3 miles from AUO. The airplane’s initial collision with a tree was approximately 150 feet before impacting the ground. The airplane then traveled approximately 60 feet before coming to rest with the left wing, flap and fuselage on top of a round hay bale. The direction of travel was approximately 040 degrees to 045degrees magnetic. Crushing of the lower cabin and right wing was consistent with the airplane having impacted the ground in 30-degree nose low, right wing down attitude, and came to a stop on a 120 degrees heading. All flight control surfaces were located and control continuity was established. The engine, engine cowling and nose landing gear were found separated from the firewall forward of the fuselage. The pilot compartment entrance door, door frame, windscreen, and side windows were found separated from the fuselage, exposing the pilot and co-pilot seats. The safety restraints were attached to the seats but had been cut by emergency medical personnel to remove the pilot and passenger. The instrument panel was inverted and folded over to the left of the crew compartment exposing the navigation and radio equipment. The pilot and co-pilot control yokes were found separated from the control column. The instrument sub-panel, engine control pedestal, control column, and rudder pedals were damaged. The fuel selector valve was selected to the right fuel tank. The fuel drain on the selector valve was opened and there was no fuel present. The fuel selector valve was removed and tested with no anomalies noted. The right wing was folded back and to the right of the fuselage. The leading edge was separated from the companion walk way out to the wing tip exposing the forward spar. The leading edge was crinkled and damaged from impact forces. The right aileron separated from the wing and was located forward and to the right of the wing. The flap was attached to the wing and damaged by impact forces. The wing tip fuel tank was separated from the wing and was located approximately 9 feet outboard of the wing. The fuel line was attached to the tip tank. The tip tank was breached but contained about 4.5 gallons of fuel. The right main fuel tank was breach and no fuel was observed. The right main landing gear was folded and located forward of the main wing spar. The left wing leading edge sustained collision damage consistent with an impact with a tree approximately 1 foot outboard of the fuselage to the wing tip. The leading edge skin was crumpled and torn in several locations exposing the fuel tank bladder and the front wing spar. The main fuel tank bladder remained intact and was not leaking; approximately 1 quart of fuel was drained from the tank. The left wing tip tank was found separated from the wing and was located approximately 37 feet forward and to the right of the main wreckage, the tip tank was breached but contained approximately .5 gallons of fuel. No evidence of fuel leakage or browned grass was observed. The flap remained attached to the wing and was bent upward from contacting a hay bale. The aileron remained attached to the wing and wa

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