Pilot Debrief

BEECH A36 near Beauregard, AL — 2009-05-15

Final reportERA09FA289
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Date
2009-05-15
Location
Beauregard, AL, USA
Aircraft
BEECH A36
Registration
N191MK
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Cruise

Probable cause

The pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation.

NTSB narrative

The pilot was on the second leg of his cross-country flight, after picking up three passengers at the intermediate airport. The passengers stated that while cruising at 7,000 feet, the engine lost power. The pilot was able to restart the engine but it lost power again. The pilot rearranged the aft passengers into the aft facing seats, and then performed a forced landing to a pasture, during which the airplane collided with trees and a large rolled bale of hay. Postaccident examination of the airplane revealed the fuel selector valve was selected to the right fuel tank and the fuel drain on the selector valve was opened and there was no fuel present. The right tip tank was breached but contained about 4.5 gallons of fuel. The right main fuel tank was breached and no fuel was observed. The left main fuel tank bladder remained intact and was not leaking; approximately 1 quart of fuel was drained from the tank. The left wing tip tank was found separated from the wing; the tip tank was breached but contained approximately 1/2 gallon of fuel. No evidence of fuel leakage or browned grass was observed. Functional testing of the engine and fuel selector valve revealed no preimpact mechanical anomalies. During the functional test of the engine, the fuel supply was intentionally interrupted by turning off the test cell fuel valve and by the disconnection of the fuel pump hose supple quick-disconnect. In both cases, after engine function ceased, fuel was present in the fuel control inlet and outlet lines. Witnesses stated that prior to the accident flight; the daughter of the pilot was seen draining what was later measured to be 25.4 gallons of fuel from the main tanks. At the time when the cross-country flight started, the airplane had approximately 48.6 gallons of fuel in the main tanks and 10 gallons of fuel in each of the tip tanks. According to performance calculations made during the investigation, the engine would have burned at least 48.6 gallons of fuel at the time the engine lost power, confirming that the pilot never utilized the fuel remaining in the tip tanks.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted the flight after first engine problem indication.

NTSB coding

Evidence available

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

Docket documents30

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