Pilot Debrief

Beech A36 near Jackson, TN — 2020-09-11

Final reportERA20LA313
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Date
2020-09-11
Location
Jackson, TN, USA
Airport
MKL
Aircraft
Beech A36
Registration
N74HS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s inadequate preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's impairment due to alcohol.

Contributing factors

Contributing to the accident was the pilot's impairment due to alcohol.

NTSB narrative

The airplane was enroute during a night cross-country flight when the pilot reported to air traffic control that he was low on fuel and needed to divert to a nearby airport. The controller approved the pilot’s request, and there were no additional communications from the pilot. The wreckage of the airplane was later located in a wooded area near the divert airport. Examination of the airframe and engine revealed no evidence of fuel at the accident scene and no evidence of pre-accident anomalies that would have precluded normal operation of the airplane before the accident. Fuel computations based on refueling records, previous flights, and estimated fuel burn rates showed the engine likely consumed all usable fuel onboard. Additionally, data downloaded from an onboard engine monitor recorded the fuel flow decreasing to zero about 6 minutes before the data ended. The pilot’s report to air traffic control that he was low on fuel, the onboard engine monitor data showing fuel flow drop to zero, and the lack of fuel at the accident scene all indicate the pilot departed with insufficient fuel onboard to complete his planned flight. This resulted in a total loss of engine power due to fuel exhaustion and impact with terrain. The pilot’s toxicology showed that ethanol was present in his femoral blood at nearly three times the regulatory limit for flying. Ethanol was also present in the pilot’s vitreous indicating that the ethanol was likely from ingestion and representative of his blood alcohol level at the time of the crash. Vitreous is relatively unsusceptible to postmortem ethanol production, and the measured proportion of ethanol in vitreous compared to femoral blood fits a typical pattern seen after consumed ethanol is absorbed. The pilot’s decision to fly with insufficient fuel to reach his destination was consistent with the known impairing effects of ethanol on awareness, decision making, and performance. Thus, effects from ethanol likely contributed to the accident.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have refueled before departure to avoid fuel issue.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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