Primary finding
Probable cause
The failure of the flightcrew to recognize that both engines were being supplied fuel only from the right wing fuel tanks resulting in loss of power in both engine due to fuel starvation. Contributing to the accident were the inoperative the left auxiliary fuel pump, the inoperative right no fuel transfer time delay relay, and inadequate manufacturing of the electrical wires associated with the left and right no fuel transfer time delay relays.
Investigator assessment
Analysis narrative
Approximately 4 days before the accident the left boost pump was noted by the accident pilot to be intermittent. Maintenance checked the pump but could not duplicate the intermittent discrepancy and the airplane was approved for return to service. Shortly after takeoff during the accident flight while operating with the crossfeed switch in the "Auto" position, the left boost pump became inoperative and the "Fuel Crossfeed" annunciator correctly illuminated alerting the flightcrew that the right boost pump was supplying fuel from the right fuel tanks to both engines. An adequate supply of fuel was available in the left fuel tanks which could have directly supplied the left engine had the flightcrew closed the crossfeed valve, but the pilot in command (PIC) continued the flight with fuel only supplied from the right fuel tanks. While descending, both engines lost power due to fuel starvation. The PIC maneuvered the airplane for a forced landing in an open field and landed hard, bounced, and came to rest upright. Postaccident inspection of the airplane revealed internal components of the left boost pump were worn resulting in an inoperative boost pump and the right no fuel transfer time delay relay was inoperative due to a broken terminal at the relay. Had the right no fuel transfer annunciation system been operative, it is likely that the flightcrew would have diverted earlier for an uneventful landing at a suitable airport. While inspection of the electrical wiring and components in the cockpit (includes the fuel control panel) occurs during a Phase 3 inspection required to be performed every 800 hours, the failures of the wires and terminal at the right no fuel transfer time delay relay was due to bending which occurred with repeated opening and closing of the panel. Postaccident inspection of 2 production airplanes of the same make and model revealed discrepancies with chafing of the relay wires against a nearby structural member.
Source record
Factual narrative
HISTORY OF FLIGHT On May 25, 2009, about 1146 eastern daylight time, a Beech C90A, N8001V, registered to Rockwood LLC, operated by Executive Airlink, Inc., was landed hard during a forced landing in a field near Yeehaw Junction, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed and activated for the 14 Code of Federal Regulations (CFR) Part 135 non-scheduled, domestic, passenger flight from Ocean Reef Club Airport (07FA), Key Largo, Florida, to Orlando Executive Airport (ORL), Orlando, Florida. The airplane was substantially damaged and there was no injury to the certificated airline transport pilot and co-pilot, or two passengers. The flight originated from 07FA about 1104 hours. Earlier on the day of the accident, the accident flightcrew flew the accident airplane to 07FA to pick up two passengers; the flight was uneventful. The flight departed 07FA for ORL with approximately 1,600 to 1,800 pounds of fuel on-board, and at approximately 1108, the flightcrew established contact with the Miami Air Route Traffic Control Center (ARTCC), and advised the controller that the flight was climbing from 5,000 to 16,000 feet. The flight continued towards the destination airport and the pilot-in-command (PIC) reported that while in the “Miami area”, he noticed the amber crossfeed light was illuminated on the annunciator panel. They looked at the emergency procedures checklist for boost pump failure but the PIC reported he did not comply with the checklist and did not change the fuel control configuration. At that time they were operating with the crossfeed and both transfer pump switches in “Auto”, and both boost pumps “On.” The PIC reported he did not see any urgency and elected to continue the flight, though he did not monitor the fuel quantity gauges. The flight was cleared to climb to 17,000 feet, then later while continuing towards the destination airport was cleared to descend to 15,000 feet. Air traffic control communications were transferred to Orlando Approach Control and at 1137, the controller advised the flightcrew to cross the BAIRN intersection at 10,000 feet which they acknowledged. At 1145:37, the flightcrew advised air traffic control that the flight needed to divert to the nearest airport. The controller advised the flightcrew of 2 nearby airports and asked them which one they would like to proceed to. The flightcrew responded and the flight was vectored towards that airport. The controller asked the flightcrew the reason to divert but there was no response; there were no further radio communications received from the flightcrew. The PIC further stated that while descending to the assigned altitude of 10,000 feet with the autopilot engaged, approximately 15 minutes from the destination airport, they both noticed the left and right red low fuel pressure annunciator warning lights illuminated, followed by loss of power from both engines. They looked for the nearest airport and the PIC was able to restart the left engine. While attempting to restart the right engine the left engine quit again. The PIC maneuvered the airplane for a forced landing in an open field and lowered the landing gear before touchdown. He reported landing hard, bouncing, and becoming airborne momentarily. After coming to rest they evacuated the airplane. The PIC further reported that at no time during the flight did either no fuel transfer warning annunciator lights illuminate. The co-pilot stated that when the crossfeed light came on, they looked at the checklist but did not recall any checklist for that annunciation. He stated they normally don't do challenge response with respect to the checklist and they did not do a challenge response related to the crossfeed annunciation. When the PIC used the checklist he did not read it aloud. The PIC advised him the airplane was OK and elected to continue the flight. The flight continued and both fuel pressure annunciators came on within seconds of each other. The PIC advised him that they lost power in both engines. Every light on the annunciator panel was on. The PIC performed restart procedures and he asked air traffic control for vectors. They were able to restart but had no power. The rest of the flight was spent getting the airplane on the ground safely. When close to the ground they had a high sink rate but the gear was put down. The airplane bounced, landed, then slid sideways. They came to a stop and the PIC began securing the airplane. They all exited the airplane; the PIC was the last person to leave. The fire department arrived 1.0 to 1.5 hours later. After they arrived, they heard a buzzing sound and the PIC said both boost pumps may be still on. He did not hear either boost pump running and went into the airplane and shutdown the entire fuel panel. He turned off the transfer, boost, and crossfeed switches. He estimated he secured the panel 2 hours after the accident. PERSONNEL INFORMATION The PIC, age 46, holds an airline transport pilot certificate with rating airplane multi-engine land rating, and commercial pilot certificate with single engine land rating. His latest first class medical certificate was issued on November 3, 2008, with a limitation to wear corrective lenses. He reported having a total flight time of 5,789 hours, and 725 hours in the accident make and model airplane. His total PIC time was 5,331 hours, of which 689 were in the accident make and model airplane. During the last 90 days he logged 111 hours in multi-engine airplanes, of which 27 were in the accident make and model airplane. The PIC reported he was hired by Executive Airlink, Inc., in November 2004, and became chief pilot in July 2008. His last airman competency/proficiency check in accordance with 14 CFR Part 135.293 titled, “Initial and recurrent pilot testing requirements”, 14 CFR Part 135.297 titled, “Pilot in command: Instrument proficiency check requirements", and also 14 CFR 135.299 titled, “Pilot in command: Line checks: Routes and airports” was performed on February 17, 2009. The flight duration was recorded to be 1.5 hours and the results were listed as "Approved." The flight was in a Beech 200 airplane. He was qualified to act as PIC in Beech 200 and C90 airplanes. The co-pilot, age 29, holds an airline transport pilot certificate with rating an airplane multi-engine land rating, and commercial pilot certificate with single engine land rating. His latest first class medical certificate was issued on January 20, 2009, with no limitations. He reported on the NTSB Pilot/Operator Aircraft Accident/Incident Report having a total time of 2,500 hours, of which 690 were in the accident make and model airplane. He indicated having 2,160 hours as PIC in all type aircraft, of which 590 were in the accident make and model airplane. In the previous 90 days he reported accruing 25 hours, of which 1 were in the accident make and model airplane. The co-pilot reported that he was hired by Executive Airlink, Inc., approximately 1 ½ years earlier, left the company, then returned to the company in March 2009. His last airman competency/proficiency check in accordance with 14 CFR Part 135.293 titled, “Initial and recurrent pilot testing requirements”, 14 CFR Part 135.297 titled, “Pilot in command: Instrument proficiency check requirements", and also 14 CFR 135.299 titled, “Pilot in command: Line checks: Routes and airports” was performed on March 23, 2009. The flight duration was recorded to be 1.2 hours and the results were listed as "Approved." The remarks section indicated, "[second-in-command] only check must fly with [pilot-in-command]." The flight was in a Beech 200 airplane. He was qualified to act as second-in-command in Beech 200 and C90 airplanes. AIRCRAFT INFORMATION The airplane was manufactured in 1990 by Beech Aircraft Corporation as model C90A, and was designated serial number LJ-1265. I