Pilot Debrief

BEECH E-55 near Broken Bow, NE — 2012-03-28

Final reportCEN12FA210
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Date
2012-03-28
Location
Broken Bow, NE, USA
Airport
BBW
Aircraft
BEECH E-55
Registration
N1567W
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain airspeed and subsequent loss of airplane control during a single-engine landing approach. Contributing to the accident was the pilot's improper fuel management during cruise flight, which resulted in an initial loss of power in both engines and the subsequent single-engine approach after power was restored on only one engine.

Contributing factors

Contributing to the accident was the pilot's improper fuel management during cruise flight, which resulted in an initial loss of power in both engines and the subsequent single-engine approach after power was restored on only one engine.

NTSB narrative

The pilot said that he noted an imbalance between the left and right main fuel tanks during cruise flight. He attempted to correct the imbalance by placing the left fuel selector in the crossfeed position so that both engines would receive fuel from the right main fuel tank. About 15 minutes after the pilot selected the crossfeed position, both engines lost power. When the pilot reset the left and right fuel selectors to the left main and the right auxiliary fuel tanks, respectively, the left engine regained power and the right engine began "surging." The pilot decided not to shut down the right engine and diverted to the nearest suitable airport. During final approach, the right engine lost power completely, and the airspeed decayed until it approached the airplane’s minimum control airspeed. When the airplane drifted right of the runway centerline, the pilot reduced power on the left engine in an attempt to maintain control. The airplane impacted an open field near the runway and a postimpact fire ensued. Postaccident examination revealed no airframe or engine anomalies consistent with a preimpact mechanical failure or malfunction. Both fuel selectors were positioned to their respective main fuel tanks. The pilot stated that the airplane was fully fueled before departure. The airplane fuel system was composed of two 37-gallon main fuel tanks and two 31-gallon auxiliary fuel tanks. The pilot stated that he had not used any of the fuel in the auxiliary tanks before the loss of engine power. The pilot's operating handbook noted that the crossfeed system was not to be used to transfer fuel from one tank to another or to balance fuel during flight. The simultaneous loss of engine power while both engines were receiving fuel from one fuel tank, the restoration of power on the left engine after switching fuel tanks, operation at or near the fuel endurance limit for the right main fuel tank, and the lack of anomalies identified during the engine exams are consistent with exhaustion of fuel in the right main tank.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have maintained fuel management without switching to crossfeed.

NTSB coding

Evidence available

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

Docket documents29

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