Pilot Debrief

BEECH 95-B55 (T42A) near San Bernardino, CA — 2011-02-07

Final reportWPR11FA125
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Date
2011-02-07
Location
San Bernardino, CA, USA
Airport
SBD
Aircraft
BEECH 95-B55 (T42A)
Registration
N225DH
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Descent

Probable cause

The pilot did not recognize the loss of power in the right engine and did not execute the proper procedures for a go-around with one engine inoperative, likely due to increased workload. Contributing to the accident was the pilot's improper in-flight fuel management, which resulted in fuel starvation of the right engine.

Contributing factors

Contributing to the accident was the pilot's improper in-flight fuel management, which resulted in fuel starvation of the right engine.

NTSB narrative

During the initial climb, the landing gear warning horn sounded. The pilot diagnosed the problem and determined that the landing gear had retracted successfully and that the indication system was in error. He continued the flight with the horn intermittently sounding. During the descent phase, the pilot was given an unexpected direct route to the airport, and, as a result, he rushed through the descent checklist items. The pilot decided to perform a low pass over the arrival runway to confirm that the landing gear had extended. The pilot said that during the low pass he started to have difficulty controlling the airplane. An onboard engine monitoring system recorded a total loss of engine power to the right engine at that time. The pilot did not recognize that his difficulty in maintaining altitude and airplane control was a result of a loss of engine power to one engine; he subsequently lost control of the airplane, which collided with a storage facility in a nose-down inverted attitude. Witness reports, photographic evidence, and a postaccident examination revealed that the pilot did not retract the landing gear and flaps after the loss of power, as instructed in the airplane's operating instructions for a go-around with one engine inoperative. The airplane's operating instructions recommend that the main fuel tanks be selected during descent and while landing. The pilot stated that he customarily uses the auxiliary fuel tanks during cruise flight and the main tanks while climbing and descending; however, both fuel selector valves were found in the auxiliary tank position at the accident site. The airplane's fuel tanks were serviced to capacity about 2.5 flight hours before the accident. Calculations of fuel consumption for the flights since the last fueling would have resulted in the use of a quantity of fuel that would have either been equal to or slightly exceeded the capacity of the auxiliary fuel tanks. Damage to the fuel system precluded an accurate assessment of the quantity and distribution of the remaining fuel onboard at the time of the accident. The engine monitoring system recorded a small rise in exhaust gas temperatures just before the loss of power; this rise is consistent with a lean fuel/air mixture, which would be present in a fuel starvation or exhaustion event. The postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The pilot's increased workload, due to the unexpected routing and possible problem with the landing gear, during the abbreviated final approach clearance and subsequent low pass could have resulted in a task overload, which resulted in his mismanagement of the fuel system during the landing phase.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot switched fuel tanks simultaneously instead of waiting 10 seconds.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • FDR / data
  • ADS-B / radar
  • Photos
  • 37 docket documents
View NTSB final reportView NTSB docket

Docket documents37

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