Pilot Debrief

BEECH C90A near Yeehaw Junction, FL — 2009-05-25

Final reportERA09FA304
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Date
2009-05-25
Location
Yeehaw Junction, FL, USA
Aircraft
BEECH C90A
Registration
N8001V
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

The failure of the flightcrew to recognize that both engines were being supplied fuel only from the right wing fuel tanks resulting in loss of power in both engine due to fuel starvation. Contributing to the accident were the inoperative the left auxiliary fuel pump, the inoperative right no fuel transfer time delay relay, and inadequate manufacturing of the electrical wires associated with the left and right no fuel transfer time delay relays.

Contributing factors

Contributing to the accident were the inoperative the left auxiliary fuel pump, the inoperative right no fuel transfer time delay relay, and inadequate manufacturing of the electrical wires associated with the left and right no fuel transfer time delay relays.

NTSB narrative

Approximately 4 days before the accident the left boost pump was noted by the accident pilot to be intermittent. Maintenance checked the pump but could not duplicate the intermittent discrepancy and the airplane was approved for return to service. Shortly after takeoff during the accident flight while operating with the crossfeed switch in the "Auto" position, the left boost pump became inoperative and the "Fuel Crossfeed" annunciator correctly illuminated alerting the flightcrew that the right boost pump was supplying fuel from the right fuel tanks to both engines. An adequate supply of fuel was available in the left fuel tanks which could have directly supplied the left engine had the flightcrew closed the crossfeed valve, but the pilot in command (PIC) continued the flight with fuel only supplied from the right fuel tanks. While descending, both engines lost power due to fuel starvation. The PIC maneuvered the airplane for a forced landing in an open field and landed hard, bounced, and came to rest upright. Postaccident inspection of the airplane revealed internal components of the left boost pump were worn resulting in an inoperative boost pump and the right no fuel transfer time delay relay was inoperative due to a broken terminal at the relay. Had the right no fuel transfer annunciation system been operative, it is likely that the flightcrew would have diverted earlier for an uneventful landing at a suitable airport. While inspection of the electrical wiring and components in the cockpit (includes the fuel control panel) occurs during a Phase 3 inspection required to be performed every 800 hours, the failures of the wires and terminal at the right no fuel transfer time delay relay was due to bending which occurred with repeated opening and closing of the panel. Postaccident inspection of 2 production airplanes of the same make and model revealed discrepancies with chafing of the relay wires against a nearby structural member.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not comply with checklist for boost pump failure after crossfeed light illuminated.

NTSB coding

Evidence available

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

Docket documents27

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