BFO94FA112

NTSB accident investigation · Beech 24R · Nantucket, MA · June 6, 1994

Accident · FatalField investigationFinal report
Date
June 6, 1994, 15:40 local (19:40 UTC)
Place
Nantucket, MA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N9258SBeech 24R
Weather
Visual (VMC) · Day
Status
Completed · report October 19, 1995
Report
Approved by Office Director
FAA report
19940606014029A
Case key
8852

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the total loss of engine power over unsuitable terrain, for undetermined reasons. The pilot's failure to ensure that proper survival equipment was onboard the airplane was a related factor.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerCruise
Reason for occurrence undeterminedCause
DitchingEmergency descent/landing
In flight collision with terrain/waterLanding
Terrain condition - none suitableCause
Terrain condition - waterFactor
Misc eqpt/furnishings,survival equipment
Miscellaneous equipment - not availablePilot in commandFactor

Analysis

While en route to the destination, the pilot advised ATC that the airplane engine had lost power, he was unable to maintain altitude and was ditching the airplane. Initial attempts to locate the wreckage and rescue the pilot were unsuccessful. There was no survival equipment on board the airplane. The airplane was recovered more than one month after the accident. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunction. The most recent known refueling occurred the day before the accident, when the airplane was reportedly fueled 'to the tabs.' This fuel load equals 15 gallons per side (30 gallons total), of which 22.4 gallons is considered useable fuel. After being fueled, the airplane was flown from Nantucket to lawrence, and was returning to Nantucket when the accident occurred. The fuel tanks were compromised during impact.

Factual narrative

History of flight

On June 6, 1994, at 1540 eastern daylight time, a Beech B24R, N9258S, owned and operated by Vest Air Leasing Inc. of Haverhill, Massachusetts, was destroyed when it impacted the ocean about 12 miles north of Nantucket, Massachusetts during a power-off forced landing. The certificated commercial pilot was fatally injured, the one passenger was not recovered and presumed dead. Visual meteorological conditions (VMC) prevailed and no flight plan was filed for the flight, which was conducted under 14 CFR Part 91. The flight departed Lawrence, Massachusetts, at 1440.

The pilot had completed a Biennial Flight Review (BFR) in the accident airplane, which was based at Lawrence Municipal Airport (LWM), in Lawrence, Massachusetts, on June 2, 1994. The flight instructor who administered the BFR stated the airplane was fueled to the tabs prior to the BFR. The airplane was flown 1.5 hours during the BFR flight. After the BFR was accomplished, the pilot and two passengers flew the accident airplane to Nantucket Memorial Airport (ACK), Nantucket, Massachusetts. There were no fuel receipts to show the airplane was refueled prior to this flight. After landing at ACK, the pilot requested the Airport Fixed Base Operator (FBO) to "fuel the plane to the tabs". Two fuel receipts, dated June 2 (19.6 gallons) and June 5 (9.5 gallons), respectively, are appended. There is no evidence that the airplane received fuel at any other time in the four days preceding the accident.

According to a family spokesperson, the pilot departed ACK at 1700 on June 5, and transported two passengers to the airport at Lawrence, Massachusetts. The pilot remained overnight in Lawrence. On June 6, the pilot and one passenger (the pilot's son) departed LWM about 1440 for the return flight to ACK.

According to Federal Aviation Administration (FAA) records, the pilot was receiving VFR Advisory Service when he reported his engine lost power. He stated that he was unable to maintain altitude and was ditching the airplane. Radar and radio communications with the accident airplane were lost at 1540. FAA Air Traffic Control (ATC) records indicate that the airplane's last observed altitude was 600 feet, at a position approximately 12 nautical miles north of the Nantucket Memorial Airport.

ATC personnel vectored two aircraft that were flying in the vicinity to the point of last radar contact. Both aircraft flew over the accident area within minutes of the ditching; neither pilot observed any airplane debris or survivors in the water. The pilot's body was recovered from the water 10 days after the airplane was ditched by a local fisherman; the one passenger was not found and presumed dead.

Personnel information

The pilot held a Commercial Pilot Certificate issued March 22, 1986, with an instrument rating for airplane single engine and multiengine land. His second class medical was dated April 12, 1994.

Examination of the pilot's flight logbook indicated his total flight time was approximately 2389 hours. Since August, 1987, the pilot had flown approximately 607 hours, with numerous trips between LWN and ACK. Of the 607 hours, 593 were flown prior to October, 1992, in either a Beech King Air or a Piper Cheyenne. Logbook records indicated that the pilot had 3 hours total flight time in the accident make and model airplane prior to the extended trip during which the accident occurred. These 3 hours were dual instructional flights. The pilot had not logged his flights after the BFR (from LWN to ACK on June 2, and the return flight from ACK to LWN on June 5). This extended trip was the first time the pilot had utilized the accident airplane without the supervision of a flight instructor. According to acquaintances, the pilot was flying the accident airplane with the intention of purchasing it and utilizing it for trips such as this, since he owned a house on Nantucket.

The flight instructor who administered the BFR stated the pilot "did a great job flying and was meticulous with the checklists." The flight instructor stated he had specifically made a sheet which showed how much useable fuel was onboard when the airplane was filled to the tabs, slots, and full. This sheet also depicted how much weight could be carried with these respective fuel loads. The instructor reported he had shown the pilot how to lean the fuel during cruise by setting 23 inches MP, 2400 RPM, and leaning the fuel to 1375-1400 degrees on the digital EGT. The flight instructor stated that after the above procedures were completed, the fuel flow meter would indicate "about 9 gallons per hour, but in fact was burning more likely, 10-10.5 gallons per hour."

Aircraft information

The accident airplane, a 1976 Beech B24R, was equipped with a single Lycoming IO-360-A1B6 (200 horsepower) engine. The aircraft maintenance records showed the most recent annual maintenance inspection was accomplished on June 1, 1994, at an engine tachometer time of 3357.79 hours. Records indicated that at that time of the annual inspection, the engine had operated 70.29 hours since major overhaul (SMOH).

The Pilot Operating Handbook (POH) for the accident airplane indicated that the airplane is capable of carrying 58 gallons of fuel (29 gallons each tank), of which 52 gallons is considered useable. In the filler neck of each tank is a visual measuring tab which permits partial filling of the fuel system. When the fuel touches the bottom of the tab it indicates 15 gallons of fuel in each tank with 22.4 total useable gallons. When filled to the slot in the tab it indicates 20 gallons of fuel in each tank with 32.4 total useable gallons. The POH also states that the indicating system (fuel gauges) reads full at 20 gallons. The pilot must visually check the fuel level during preflight to ascertain desired level. Adjacent to the engine instrument cluster, there is a placard which states, "DO NOT TAKE OFF WHEN FUEL QUANTITY GAUGE INDICATES IN YELLOW OR WITH LESS THAN 11 GALLONS IN EACH MAIN TANK."

Information received from the airplane manufacturer indicated that the power setting to which the flight instructor taught the pilot to lean to corresponds with a cruise power setting of 65% maximum continuous power. The manufacturer's information indicated that, on a standard day at that power setting, a pilot could expect a fuel flow of 9.1 GPH.

Meteorological information

The ACK weather observation taken at 1545 estimated the ceiling at 5000 feet broken, 15000 feet overcast, with visibility of 10 miles. The temperature was 63 degrees, dewpoint 57 degrees, the winds were from 240 degrees at 10 knots, altimeter 30.00" Hg. At 2000, the observed winds aloft taken from Chatham, Massachusetts, showed winds from approximately 230 degrees at 35 knots between 1000 and 3000 feet. It is unknown if the pilot obtained weather information prior to his departure.

Wreckage and impact information

The aircraft was located several days after the accident using Sonar equipment. The LORAN latitude/longitude coordinates for the aircraft wreckage were 041 degrees, 27 minutes, 96 seconds North, and 070 degrees, 10 minutes, 88 seconds West. The aircraft was intact. An attempt to salvage the aircraft on June 23 was unsuccessful as the barge capsized after the aircraft was raised out of the water. The aircraft was recovered on July 8 and transported to LWM for examination.

Both cabin doors were found in the open position, and both front seat belts were found unbuckled. The instrument panel and cockpit controls exhibited no impact damage. The throttle control lever was in the full aft position. The mixture and propeller controls were found in the full forward positions. The landing gear and flap switches were found in the UP position. The flap position indicator exhibited an UP indication. The magneto switch was found in the left position with the key missing. The battery, alternator, and boost pump switches

Aircraft

Registration
N9258S
Reported as
Beech 24R
Category
Airplane
Serial number
MC-388
Airframe hours
3,364
Engine
Lycoming IO-360-A1B6, 200 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Marden, Reginald
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 1, 1994 · 6 hours before
Departed
LWM · Lawrence, MA
Destination
ACK · Nantucket, MA

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
2,389 total · 8 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 10 knots
Visibility
10 statute miles
Lowest ceiling
5,000 ft broken
Temperature
63 °F, dew point 57 °F
Altimeter
30.00 inHg
Observed at
ACK, 12 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.