Pilot Debrief

BEECH A36 near Marshville, NC — 2016-02-19

Final reportERA16FA108
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Date
2016-02-19
Location
Marshville, NC, USA
Aircraft
BEECH A36
Registration
N61WB
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's improper preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the severity of the pilot's injuries was his failure to have a properly secured shoulder harness at the time of the accident.

Contributing factors

Contributing to the severity of the pilot's injuries was his failure to have a properly secured shoulder harness at the time of the accident.

NTSB narrative

The airline transport pilot departed on the instrument flight rules cross-country flight in night visual meteorological conditions with about 45 gallons of fuel, which, based on fuel burn rates, was sufficient for about 3 hours of flight. About 3 hours after departure and 50 miles from the destination airport, the pilot told air traffic control he was having engine problems and requested a vector to the nearest airport. A witness near the accident site heard the airplane descending and described the sound of an engine being re-started several times. The airplane came to rest in wooded terrain. Postaccident examination revealed the wing bladder tanks were intact, and no visible fuel was observed in either tank. When the wings were removed, a total of less than 2 quarts of fuel was drained from both the left and right fuel tanks. Examination of the airplane and engine revealed no pre-accident mechanical deficiencies that would have precluded normal operation. The pilot was aware that the left and right fuel tank bladders were bulging prior to the accident flight. The bulging fuel bladders may have resulted in erroneous fuel quantity readings during the flight. Given the absence of fuel in the airplane's fuel tanks and the length of flight that corresponded to the fuel available, the pilot likely departed without sufficient fuel to complete the flight to the intended destination and the loss of engine power was likely the result of fuel exhaustion. The pilot was found deceased, slumped over in the left seat, still wearing his lap belt. Although the airplane was equipped with a single shoulder harness (across the left shoulder), it was not secured to the lap belt at the time of the accident. The pilot's failure to have properly secured the shoulder harness at the time of the accident likely contributed to the severity of his injuries. Examination of the pilot's seatbelt and shoulder harness assembly revealed that the seat belt shoulder harness attachment post elastic grommet was not installed, nor was it found in the wreckage. When manually assembled, the shoulder harness attachment buckle would not seat securely to the seatbelt attachment post.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not refuel adequately at DAB despite indications of low fuel.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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