Pilot Debrief

BEECH B24R near Dayton, VA — 2012-08-26

Final reportERA12FA526
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Date
2012-08-26
Location
Dayton, VA, USA
Aircraft
BEECH B24R
Registration
N9200S
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The pilot's improper fuel management, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the noninstrument-rated pilot's decision to attempt a visual flight rules flight in instrument meteorological conditions over mountainous terrain.

Contributing factors

Contributing to the accident was the noninstrument-rated pilot's decision to attempt a visual flight rules flight in instrument meteorological conditions over mountainous terrain.

NTSB narrative

Before departing on the accident flight, the noninstrument-rated pilot obtained a weather briefing and was advised several times that visual flight rules (VFR) flight was not recommended due to existing and forecast instrument meteorological conditions (IMC) along his intended route of flight. The pilot then departed on a VFR flight without filing a flight plan. More than 2 hours after departure, the pilot contacted air traffic control (ATC) and advised that he was climbing the airplane from 9,000 to 10,500 feet. Two minutes later, the pilot declared an emergency and advised ATC that he had "lost" the engine. The controller provided vectors to nearby airports, attempting to orient the pilot to the airplane's position relative to the airports so that he could acquire the airports visually. However, the pilot advised that he was "still in the soup and can't see much of anything at this point." About 5 minutes later, the pilot stated that the airplane was unable to clear a ridgeline in its flightpath, and shortly thereafter, radar and voice communication with the airplane was lost. The airplane collided with trees and terrain before reaching a suitable landing site. Examination of the wreckage and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The fuel tanks were intact, and about 1 pint of fuel was drained from the left tank and 10 gallons were drained from the right. The fuel selector was found positioned to the right tank. Continuity of the entire fuel system was confirmed. Disassembly of the gascolator found that it contained no fuel, was completely dry, and was absent of debris. At the time of departure, each fuel tank contained 26.1 gallons of usable fuel. According to the manufacturer's pilot operating handbook, the airplane would consume 10.2 gallons per hour at 75 percent maximum continuous power. Given the fuel capacity of each tank, continuity of the fuel system, dry fuel system components, and published fuel consumption rates, it is likely the pilot exhausted the fuel supply in the left tank. It is likely that the engine lost power due to fuel starvation, and the pilot switched the fuel selector to the right tank but was unable to restore engine power before encountering a ridgeline in IMC. Toxicological testing and a review of the pilot's medical records revealed the contraindicated use of anti-depressant medication, which was not declared on his most recent medical certificate application.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot should have canceled the flight due to IMC warnings received during preflight briefing.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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