Pilot Debrief

BEECH D55 near Conway, SC — 2013-08-03

Final reportERA13FA348
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Date
2013-08-03
Location
Conway, SC, USA
Airport
HYW
Aircraft
BEECH D55
Registration
N7641N
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot's loss of airplane control, which resulted from his failure to follow the loss of single engine power checklist procedures after a total loss of right engine power due to fuel starvation. Contributing to the accident was the pilot's improper preflight fuel planning and in-flight fuel management.

Contributing factors

Contributing to the accident was the pilot's improper preflight fuel planning and in-flight fuel management.

NTSB narrative

After departing on the accident flight, the pilot performed a practice instrument approach to an airport located about 25 minutes away. Onboard video taken during the final portion of the approach showed that the right main fuel tank had about 5 gallons of fuel remaining (about 20 minutes of flight at the computed consumption rate), which was below the minimum fuel quantity specified for takeoff in the pilot's operating handbook (POH). Instead of landing after the approach, the pilot chose to continue the flight and return to his home airport. While on final approach for landing and about 600 ft above the ground, the airplane made a steep, 270-degree right turn, departed controlled flight, and crashed at the entrance to a housing development. Examination of both engines and their propellers revealed evidence consistent with the left engine operating at high power and with the right engine operating at low or possibly no power at impact. Disassembly of each engine revealed no evidence of any preimpact mechanical malfunctions or failures. Based on the limited fuel in the right main fuel tank on the previous approach and the lack of power at impact, it is likely that the right engine lost power due to fuel starvation. All of the engine controls were found full-forward in their quadrants, and the right engine propeller was not feathered. The POH engine failure checklist stated that the controls on the inoperative engine should be closed and that the inoperative engine should be feathered. The POH also noted that, in the event of an engine failure, it is necessary "to maintain lateral and directional control" by operating the airplane above the single-engine minimum controllable airspeed (Vmca). The published Vmca for the accident airplane was 80 knots, and performance calculations revealed that the airplane slowed to below 80 knots. Based on the airplane's configuration at impact and the performance calculations, it is likely that the pilot did not follow the POH checklist procedures for a loss of single engine power and that he subsequently lost control of the airplane. A review of the pilot's medical records revealed that he been prescribed medications for the treatment of depression and anxiety, and toxicological testing revealed the presence of sertraline, a medication used to treat depression, in the pilot's liver and blood. However, based on the evidence, it is unlikely that the pilot was impaired by depression or the medication he used to treat it at the time of the accident.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not manage fuel levels properly before approach.

NTSB coding

Evidence available

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

Docket documents21

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