Pilot Debrief

BEECH A36TC near Chatlottesville, VA — 2013-12-18

Final reportERA14FA075
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Date
2013-12-18
Location
Chatlottesville, VA, USA
Airport
CHO
Aircraft
BEECH A36TC
Registration
N3705Z
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to position the fuel selector handle in a fuel tank detent, which resulted in a total loss of engine power due to fuel starvation. Contributing to the pilot’s fatal injuries was the separation of his shoulder harness due to overload in an area of excessive fraying.

Contributing factors

Contributing to the pilot's fatal injuries was the separation of his shoulder harness due to overload in an area of excessive fraying.

NTSB narrative

About 1 hour 30 minutes into the cross-country flight and while on approach to the destination airport, the pilot reported a loss of engine power. The pilot was unable to glide the airplane to the airport, and it subsequently impacted trees and the ground in a residential area about 3 miles from the airport. The pilot had completely fueled the airplane before departure, and adequate fuel remained onboard at the time of the engine power loss. Examination of the wreckage revealed that the three-position fuel selector handle was positioned in between the left and right tank detents, which would have restricted fuel flow to the engine. A subsequent test run of the engine was performed successfully, and no evidence of mechanical malfunctions or failures was found that would have precluded normal engine operation. The airplane's before landing checklist instructed the pilot to move the fuel selector valve to the fuller fuel tank for landing. It is likely that, while on approach and preparing the airplane to land, the pilot switched fuel tanks and then inadvertently failed to ensure that the fuel selector handle was fully positioned in the detent of the fuel tank he intended to select. During the impact sequence, the pilot's shoulder harness separated, and his cause of death was attributed to blunt force trauma to the torso. The autopsy also reported a near-complete transection of the thoracic aorta. If the pilot's shoulder harness had remained intact, the risk of traumatic transection of the aorta would have been significantly reduced and, thus, the pilot likely would only have incurred serious, not fatal, injuries. Examination of the shoulder harness revealed that the belt had separated about 31 inches from where the fastener connected to the lapbelt. The location of the separation corresponded approximately to where the belt would pass through the D-ring behind the pilot's shoulder. The belt separation area exhibited about 0.25-inch fraying on one edge and 1.25-inch fraying on the other edge along a total area of about 7.75 inches. The shoulder harness manufacturer's component maintenance manual states that the acceptable limit for webbing fraying was a 6-inch area. Microscopic examination of the separated fibers revealed that they had separated in overload. The airplane's maintenance manual and a Federal Aviation Administration advisory circular contained information pertaining to the inspection of shoulder harnesses during 100-hour or annual inspections. The accident airplane's most recent annual inspection was completed about 1 month before the accident. Although the pilot's toxicology report was positive for pain medication, the medication was not detected in his blood; thus, it is likely that the pilot took the medication many hours before the accident flight and was not impaired during the flight.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have selected a full fuel tank before approach.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

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