Pilot Debrief

BEECH 35 A33 near Helenwood, TN — 2018-01-30

Final reportANC18FA022
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Date
2018-01-30
Location
Helenwood, TN, USA
Aircraft
BEECH 35 A33
Registration
N9378Y
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

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.

Contributing factors

Contributing to the accident was the pilot's failure to follow the air start checklist.

NTSB 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.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have checked fuel levels before departure from Winder, Georgia.

NTSB coding

Evidence available

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

Docket documents8

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