Pilot Debrief

RAYTHEON AIRCRAFT COMPANY A36 near Yorktown, NY — 2012-04-20

Final reportERA12LA295
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Date
2012-04-20
Location
Yorktown, NY, USA
Aircraft
RAYTHEON AIRCRAFT COMPANY A36
Registration
N821SM
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Cruise

Probable cause

The pilot's improper placement of the fuel selector, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the pilot's failure to perform the published emergency procedure by the checklist.

NTSB narrative

The airplane was in cruise flight at 7,000 feet when the engine lost power. The pilot requested vectors to the nearest airport but determined the airplane would not reach the requested landing site. He selected a forced landing site on a corporate complex and completed the forced landing, which resulted in substantial damage to the airplane. During the descent, he stated that he performed remedial actions in accordance with the checklist and switched the fuel selector from the right tank position to the left tank. Later, the pilot stated that he did not consult a checklist, but performed emergency action items "from memory." He added that the engine would surge during the descent but would not produce sufficient power to maintain altitude. A witness stated that he saw the airplane at low altitude near the campus and described the engine sound as surging between idle and "extremely high rpm." He said that the engine sounded as though it was "starving for fuel." Examination of the airplane revealed no preimpact mechanical anomalies. The fuel selector was found in a position between the left tank and right tank detents. A detailed examination revealed continuity of the fuel system, unobstructed fuel lines and filters, and an operational fuel selector. The engine was removed from the airplane and placed in a test cell, where it started immediately, accelerated smoothly, and ran continuously without interruption. The engine run revealed no anomalies that would have prevented normal operation and the production of rated power. A warning in the airplane manufacturer's Pilot's Operating Handbook stated: "POSITION [Fuel] SELECTOR IN DETENTS ONLY – NO FUEL FLOW TO ENGINE BETWEEN DETENTS" It is likely that the pilot moved the fuel selector during cruise flight but did not ensure that it was seated correctly in the detent. Shortly thereafter, the engine lost power. Because the pilot did not perform the requisite emergency procedures, he did not recognize that the fuel selector was not seated properly.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not consult checklist during descent for engine power loss.

NTSB coding

Evidence available

  • Video
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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