Pilot Debrief

BEECH C23 near Hot Springs, AR — 2013-06-30

Final reportCEN13LA381
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Date
2013-06-30
Location
Hot Springs, AR, USA
Airport
HOT
Aircraft
BEECH C23
Registration
N3KT
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Descent

Probable cause

The pilots’ failure to monitor and manage fuel consumption during cruise flight, which resulted in fuel exhaustion and a subsequent forced landing.

NTSB narrative

The airplane departed with 50 gallons of fuel onboard (confirmed by receipts and a lineman) of which 2.6 gallons was unusable. The pilots verified that the fuel was correct and was not contaminated. During the flight, they appropriately leaned the mixture for each altitude at which they were flying. About 1 hour into the flight, they switched to the left fuel tank, and about 1 hour 42 minutes later, they switched back to the right fuel tank. About 8 miles from the airport, the engine lost power. The pilots turned on the fuel pump, and the engine regained power briefly. They selected the left fuel tank, and the engine again regained power. The pilots expected to make the airport and estimated that 8 gallons of fuel remained, which would have met required fuel reserves. About 3 miles from the airport, the engine lost power again. The pilots switched to the right fuel tank. However, the engine produced short "bursts of power." At this point, the left seat pilot turned control over to the right seat pilot. A small, clear, grassy area was selected for a forced landing. The left wing impacted a tree, and the nose hit another tree. An examination of the airplane revealed that the fuel tanks were intact. The flight's fuel planning was reviewed and found to be adequate to complete the flight. Using the manufacturer's "best power" fuel mixture setting, 41.6 gallons of fuel would be needed to complete the flight. However, 26 ounces of fuel was recovered from both fuel tanks. The pilots stated the fuel gauges worked during the flight. The pilot operating handbook indicated that it is "the pilot's responsibility to ascertain that the fuel quantity indicators are functioning and maintaining a reasonable degree of accuracy, and to be certain of ample fuel for a flight." It is likely that the pilots did not use the best power fuel mixture setting throughout the flight, thus burning more fuel than they had planned for the flight. However, they should have been monitoring the fuel consumption and landed before the fuel was exhausted.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilots should have ensured adequate fuel before departure.

NTSB coding

Evidence available

  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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