Pilot Debrief

BEECH A23 near Kingston, TN — 2016-01-16

Final reportERA16LA090
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Date
2016-01-16
Location
Kingston, TN, USA
Airport
12TN
Aircraft
BEECH A23
Registration
N3680Q
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

The pilot's inadequate preflight inspection and fuel planning and his improper in-flight fuel management, which resulted in a total loss of engine power due to fuel starvation.

NTSB narrative

The private pilot performed maintenance on the airplane about 2 weeks before the accident, which included replacing the fuel tank cap O-rings and draining the fuel from the left tank and putting it in the right fuel tank in order to clear debris from the left tank sump valve. Following that work, the pilot believed that the airplane's right fuel tank contained about 28 gallons of fuel and the left fuel tank contained about 1.5 gallons. On the morning of the accident flight, he performed a preflight inspection of the airplane but could not recall if he visually verified the fuel quantity in each tank. After flying around the local area for about an hour with the fuel selector positioned to the right fuel tank, the engine experienced a total loss of power. The pilot performed a forced landing, during which the airplane was substantially damaged. The pilot reported that he kept the fuel selector positioned to the right fuel tank for the entirety of the flight and did not select the left fuel tank after the loss of engine power because he believed it only contained 1.5 gallons of fuel. Examination of the airplane after the accident revealed that the fuel selector was in the right fuel tank position, both fuel tanks were intact, and the right fuel tank was empty. The left tank contained about 7 gallons of fuel. A cursory postaccident examination of the engine found no evidence of any mechanical deficiencies. Given that the pilot used the right fuel tank for the entirety of the flight and that the right fuel tank was found intact and empty after the accident, it is likely that the loss of engine power was the result of fuel starvation.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not verify fuel levels before flight, leading to fuel starvation.

NTSB coding

Evidence available

  • Photos
  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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