WPR22FA196

The pilot’s failure to maintain proper airspeed during a turn and his exceedance of the airplane’s critical angle of attack, which resulted in an accelerated stall. Contributing to the accident was the improper placement of the fuel selector, which resulted in fuel starvation and a partial loss of engine power.

The accident pilot was a partial owner of the accident airplane, which had not flown for several months until he attempted to fly the airplane about 2 weeks before the accident. During this previous flight the pilot and his student were forced to abort two takeoff attempts after the airplane failed to climb. The pilot and pilot-rated passenger, who was also a flight instructor, had planned to fly the airplane on the day of the accident to troubleshoot the performance deficiency. During takeoff on the accident flight, the airplane reached an intermediate altitude before it started to settle momentarily. The airplane then continued to climb to a peak altitude of about 100 ft above ground level and then it started a right turn that progressively became steeper. Subsequently, the airplane impacted the ground in a nose-down attitude. An analysis of the engine harmonics during takeoff suggested that the engine may have encountered anomalies when the airplane began its right turn, but this could not be substantiated as postaccident examination of the airframe and engine did not reveal any preimpact mechanical anomalies. The fuel selector was found between the RIGHT tank detent and the OFF position at the accident site. During the flight 2 weeks earlier the accident the pilot had placed the handle in a similar position before takeoff. As there were no preimpact mechanical anomalies with the engine, it is likely that the improper placement of the fuel selector in the OFF position during takeoff resulted in fuel starvation and a partial loss of engine power. Performance computations indicated that the airplane was capable of a successful takeoff as it was below its maximum gross weight. The airplane’s center of gravity (CG) was nose-heavy, which likely would have resulted in difficulty in lifting the nose during takeoff and during reduced power situations. However, this CG condition is only likely to have affected takeoff and likely did not contribute to the accident. Recorded data suggests the airplane entered an accelerated stall in the turn when it exceeded the critical angle of attack without maintaining adequate airspeed. The investigation was unable to determine if the pilot-rated passenger was aware of the airplane’s takeoff issues 2 weeks before the accident. It is also unclear who was piloting the airplane in its final moments; however, the pilot was likely flying at the time considering he was a part owner in the airplane and given his motivation to troubleshoot the performance deficiency. While cardiovascular conditions placed the pilot at an increased risk for a sudden cardiac event, operational evidence does not suggest that this occurred and was likely not a factor in this accident.

According to the coroner, the pilot’s cause of death was multiple blunt force injuries. The forensic pathologist reported that the pilot’s heart displayed a 50% occlusion of his left anterior descending coronary and 90% occlusion of his first diagonal branch. According to the witness, about 2 weeks before the accident, the pilot decided to fly the airplane after it had sat undisturbed in its hangar for some time. The airplane’s operating records indicated that it was last flown about 6 months before. They filled the tanks with 20 gallons of fuel in each tank and then completed a preflight inspection and an engine run-up before they began their takeoff roll on runway 31. The witness was flying the airplane from the left seat at the time. After the airplane lifted off the runway and reached about 40 ft above ground level in a climb, the airplane “stopped climbing, but didn’t appear to lose any rpms.” The pilot took control of the airplane, decreased engine power and landed the airplane on the remaining portion of runway 31. They made a subsequent takeoff attempt with the same result. The witness stated that the pilot then called the pilot-rated passenger, an experienced flight instructor, to help him “figure out what was happening with it.” Fuel System The fuel system is comprised of a fuel tank located in each wing’s leading edge, each with a capacity of 29.9 gallons (including unusable fuel, which is 0.5 gallons per side). Fuel is fed from the selected fuel tank through a fuel selector valve, a fuel strainer, and the electric fuel boost pump before it reaches the engine-driven fuel pump and then the carburetor. According to the system description in the pilot’s operating handbook, “The fuel selector valve handle is located on the floorboards between the pilot and copilots seats. Takeoffs and landings should be made using the tank that is more nearly full. If the engine stops because of insufficient fuel, refer to the EMERGENCY PROCEDURES Section for the Air Start procedures.” The accident airplane was equipped with the fuel selector stop on the selector valve guard as required by Federal Aviation Administration (FAA) Airworthiness Directive (AD) 85-05-02. An entry in the aircraft maintenance logbook from November 6, 2021, showed that the fuel selector was inspected in accordance with AD 75-01-04, which requires the owner to replace the selector valve guard and inspect the valve for binding and to ensure complete shutoff. Cessna vs. Beech Musketeer Fuel Selectors The Beech Musketeer fuel selector handle is equipped with a pointer and a handle end. To select the desired tank, the operator is required to rotate the handle until the pointer faces the desired fuel tank. This position would place the handle end opposite the desired fuel tank (see Figure 1). Figure 1: Beech Musketeer Exemplar Fuel Selector In the accident airplane the rounded portion of the fuel selector handle, as indicated in Figure 1, would need to be placed over the selected fuel tank. Figure 2: Cessna 182 Fuel Selector The fuel selectors in Cessna 172 and 182 model airplanes, which the pilot was familiar with flying, require the operator to place the handle over the desired tank. For example, to select the left fuel tank, the pilot would place the handle over this placarded position (see Figure 1). The witness reported that during their previous flight 2 weeks before when he was receiving instruction, he observed the pilot place the handle end of the fuel selector over the L TANK position , as in the Cessna and not in the accident airplane. . According to the pilot-rated passenger’s flight logbook entries for the previous 12 months, he had accumulated most of his flight time that year in mostly Cessna 172 and 182 model airplanes. A recent flight record was not recovered for the accident pilot, but a flight logbook from 2011 to 2014 showed that most of his experience during this time frame was in Cessna 172 model airplanes. The witness reported that the accident pilot owned and operated a variety of different Cessna 172 airplanes in his flight history. According to the witness, who was also a student of the pilot’s, on the morning of the accident he communicated his concerns about the airplane “not wanting to fly.” The pilot responded that “the airplane wants to fly” and when the witness pushed the issue further, the pilot said, “the airplane wants to climb…this airplane was born to fly.” The witness further reported that he had always felt that the pilot was safety minded before the accident. On June 2, 2022, about 1218 Pacific daylight time, a Beech 19A Musketeer airplane, N7641R, was substantially damaged when it was involved in an accident near Oroville Municipal Airport (OVE), Oroville, California. The pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a video of the accident flight captured by a witness, who was also a student of the accident pilot, the pilot and passenger completed an engine run-up and subsequently taxied to runway 13 where they began a ground run. Data retrieved from an onboard recorder showed that the airplane started the ground run about 1218:00. The engine sounded smooth and continuous in the video as the airplane lifted off the runway in about 1,300 ft and transitioned into a climb. About 15 seconds later the airplane began to descend. The airplane started another climb about 4 seconds later, which was immediately followed by a right turn. The data recorder showed that the airplane reached a peak altitude of about 282 ft mean sea level (msl) (about 107 ft above ground level) at 1218:39 before it started to descend. The airplane’s rate of turn began to increase during the turn, at which time the video ceased. The final data point from the recorder was taken at 1218:43 and captured the airplane at an altitude of 272 ft msl and a groundspeed of 53 kts. The witness reported that the airplane impacted the ground seconds after he terminated the video to assist the occupants of the airplane. The witness reported that he flew the accident airplane with the pilot about 2 weeks before the accident. After an uneventful preflight inspection and engine run-up they taxied to runway 31 where they began a ground run. They performed two attempted takeoffs and aborted both after the airplane failed to climb. According to the witness, the pilot and pilot-rated passenger had planned to fly the airplane on the day of the accident to troubleshoot the performance deficiency. Photograph 1: Accident site from the southeast The airplane came to rest in an approximately 40° nose-down attitude on a heading of about 097° magnetic, about 500 ft south of the departure end of runway 13. All major structures were accounted for at the accident site. The left wing remained attached to the fuselage, and the right wing was partially separated at the wing root. The fuselage frame was deformed about midspan and the tail was canted slightly left of the fuselage. Both the stabilator and rudder remained connected to the empennage at their attachments. The engine remained attached to the engine firewall, which was wrapped around the engine accessory case. Both propeller blades remained attached to the propeller hub, which was still connected to the engine crankshaft. The fuel selector was found between the RIGHT tank detent and the OFF position at the accident site; however, the fuel selector was deformed and exhibited upward bending at its aft end. In addition, the selector’s left silver handle alignment bracket displayed upward bending at the aft end. Disassembly of the fuel selector revealed metallic particles along the circumference of the LEFT, RIGHT, and ENGINE ports. While the selector exhibited some slight resistance, none of the ports were obstructed. Postaccident wreckage examination did