Pilot Debrief

BEECH A23 near Pinnacle, NC — 2021-06-01

Final reportERA21FA237
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Date
2021-06-01
Location
Pinnacle, NC, USA
Aircraft
BEECH A23
Registration
N8780M
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

The flight instructor’s mismanagement of the available fuel, which resulted in a total loss of engine power due to fuel starvation.

NTSB narrative

The student pilot and flight instructor departed on a local training flight. After about 39 minutes, the engine lost total power. Flight track information indicated that the airplane continued to descend, and the last flight track target showed the airplane descending through 1,075 ft mean sea level (msl) at a groundspeed of 64 knots. The elevation at the accident site was about 1,000 ft. The airplane impacted a grass field and sustained substantial damage to the wings and fuselage. Review of the airplane’s flight log indicated that the airplane flew 2.8 hours since it was most recently fueled to capacity (58.8 gallons usable) one week before the accident, and that the airplane departed on the accident flight with the left-wing tank about 2/3 full and the right-wing tank about 1/2 full. The fuel consumption indicated by the flight log was consistent with about 14 gallons per hour. Postaccident examination of the engine and fuel system revealed that the left main fuel tank was breached; the right fuel tank, which remained intact, contained about 1 pint of fuel. The fuel selector was in the right tank position. Portions of the fuel system contained a trace amount of fuel, and no fuel was found in the fuel flow divider. When tested, the electric boost pump functioned normally. Other than the absence of fuel, no anomalies were noted with the engine that would have precluded normal operation. Based on the available information, it is likely that the loss of engine power was the result of fuel starvation when the fuel supply in the right tank was exhausted. The procedure for a loss of engine power in the pilot operating handbook included switching the fuel tanks; had the flight instructor switched the fuel selector from the right to the left-wing tank, it is likely that engine power would have been restored.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Fuel selector valve not switched to other tank after engine power loss.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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