Pilot Debrief

Beech 95B55 near Chadron, NE — 2019-07-24

Final reportCEN19FA236
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Date
2019-07-24
Location
Chadron, NE, USA
Airport
CDR
Aircraft
Beech 95B55
Registration
N8910U
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Descent

Probable cause

The pilot's failure to ensure adequate fuel was on board before departing and his in-flight fuel management, which resulted in a total loss of engine power due to fuel exhaustion.

NTSB narrative

After a 10-minute engine-running ground delay, the pilot and two passengers departed on a 640 nautical mile (nm) cross-country flight in a multiengine airplane. A witness at the destination airport reported that the airplane entered the traffic pattern and was turning on a left base leg when the airplane nosed straight down and did not pull up. Another witness near the accident site reported that she heard an engine “sputter” as if it lost power. The airplane descended into a tree line and impacted the ground 0.25 nm north of the intended runway. Postaccident examination of the wreckage revealed that the propeller blades for both engines did not exhibit any rotational signatures, which is consistent with the engines not producing power at the time of impact. Disassembly and examination of each engine did not reveal any mechanical malfunctions that would have precluded normal operation. Further examination revealed that the airplane’s fuel tanks were all breached, and there was no odor of fuel at the accident site and no fuel blighting around the wreckage. The fuel system contained a minimal amount of fuel. The fuel quantity transmitters, were which likely original to the airplane, were measured for proper resistance during range of travel; of the 19 different electrical resistance checks, only 3 were within the manufacturer’s specified limits. The fuel transmitters with improper resistances would have likely provided false readings to the fuel gauges. The airplane’s maintenance records did not contain any logbook entries related to the fuel gauges or transmitters. In addition, the airplane’s fuel flow indicator, which required the pilot to input the initial fuel amount on board the airplane, had sustained extensive damage; thus, its preaccident operating condition could not be determined, and it did provide reliable information. If the pilot was using the fuel flow indicator as the main fuel quantity indication and input the wrong amount of fuel into the unit before takeoff, then he would have had inaccurate fuel quantity indication throughout the flight. The pilot’s flight planning navigation logs show that he intended to depart with 134 gallons of fuel, which should have been adequate, even with the ground delay before departure, to reach the destination airport. The airplane was fueled 2 days before departure; the line service employee who fueled the airplane had noted that the auxiliary tanks were already full and stated that the pilot likely wasn’t present for the fueling. Based on the available evidence, it is likely that the pilot did not verify the fuel quantity before he departed on the accident flight and departed with less fuel than he had planned for, which resulted in a total loss of engine power due to fuel exhaustion.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have opted for a fuel stop at GRN instead of CDR.

NTSB coding

Evidence available

  • FDR / data
  • ADS-B / radar
  • Photos
  • 25 docket documents
View NTSB final reportView NTSB docket

Docket documents25

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