# NTSB BFO96LA021: Beech E55, N36SV, Manassas, VA, November 13, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: November 13, 1995, 13:45 local (18:45 UTC) - Place: Manassas, VA - Location: 38.7230° N, 77.5154° W: Placed by OpenAirDocs at Washington Manassas Harry P. Davis Field (HEF), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=38.7230&lon=-77.5154&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report January 17, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 9114 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO96LA021 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9114/pdf - Page: https://openairdocs.org/ntsb/BFO96LA021 ## Probable cause failure of the pilot to maintain control of the airplane, when the left engine lost power shortly after liftoff. Related factors were the pilot's failure to follow the checklist procedure, and his failure to ensure that the fuel selector was in the proper position for takeoff, which resulted in fuel starvation to the left engine. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - initial climb - 1 engine - checklist - not followed, pilot in command (contributing factor) - fluid,fuel - starvation (cause) - fuel tank selector position - improper, pilot in command (contributing factor) - Loss of control - in flight, takeoff - initial climb - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, takeoff ## Analysis The pilot estimated that there was about 60 gallons of fuel onboard the airplane at the time of departure, of which more than two thirds was in the main tanks. The pilot reported that during ground operations, he switched the fuel selector valves to the aux position in an attempt to conserve fuel in the main tanks. He said that he intended to switch back to the main tanks before takeoff, in accordance with the checklist procedure, but forgot. The pilot reported that as the airplane lifted off and he reached for the landing gear handle, the left engine lost power and the airplane snap rolled to the left. Witnesses reported that the airplane impacted the ground on its left wing and cartwheeled beside the runway. A bulletin from the aircraft manufacturer stated, '...If the auxiliary tanks are...selected for takeoff...it is possible for air to enter the auxiliary tank outlet, leading to power interruption.' There was no evidence of preimpact mechanical failure. ## Factual narrative On November 13, 1995, at 1345 eastern standard time, a Beech, E55, N36SV, impacted the ground shortly after liftoff from runway 16L at Manassas Regional Airport, Manassas, Virginia. The pilot, the sole occupant, received minor injuries and the airplane was destroyed. An Instrument Flight Rules (IFR) flight plan was filed and visual meteorological conditions prevailed at the time of the accident. The flight was conducted under 14 CFR Part 91 and the intended destination was Montgomery County Airpark in Gaithersburg, Maryland. The pilot reported that earlier on the day of the accident, he flew from Concord, New Hampshire, to the Manassas Regional Airport. He stated that when he departed New Hampshire, the airplane had full fuel tanks (132 gallons useable fuel). The pilot stated that the flight from New Hampshire took approximately 2.5 to 3 hours. He calculated that he had about 60 gallons of fuel remaining, so he decided not to refuel before the short flight from Manassas to Gaithersburg, Maryland. The pilot stated that of the 60 gallons remaining, more than two thirds was in the main tanks. The pilot reported that before he departed from Manassas Regional Airport, he conducted a normal preflight inspection and followed checklist procedures to start the airplane. He stated that all preflight checklist items were performed as listed, with one exception: he switched the fuel selector valves from the "MAIN" to "AUXILIARY" position. He stated that he intended to use the fuel in the auxiliaries while on the ground for warm up and taxi, in order to retain maximum useable fuel in the main tanks for the flight to Gaithersburg. The pilot stated that his intentions were to switch back to the main tanks prior to takeoff. Postaccident investigation revealed that in November, 1993, Beech issued Mandatory Service Bulletin #2449, which stated: "Beechcraft Baron airplanes manufactured prior to 1974 and all Travel Air airplanes were equipped with auxiliary fuel tanks that were placarded for and limited to level flight only. If the auxiliary tanks are incorrectly selected for takeoff or go around from landings...it is possible for air to enter the auxiliary tank outlet, leading to power interruption. Auxiliary fuel tanks are to be used during level flight only and not for takeoff or landing." The Beech E55 Pilot Operators Handbook (POH) stated: "Takeoff and land on main fuel tanks only." A placard between fuel selector handles stated "...use aux tanks and cross feed in level flight only." One item in the BEFORE STARTING checklist states: fuel selector valves - CHECK OPERATION THEN SET TO MAIN. A witness who helped the pilot out of the wreckage recorded switch positions prior to turning all switches off. He recorded that the fuel selector valves for both engines were in the aux tank position. The pilot reported that he forgot to switch the fuel selector valves from the auxiliary position back to the main tanks prior to takeoff. He stated: "I believe that the tanks were not switched to the mains, resulting in the sudden loss of left engine power at low altitude and airspeed. The power loss caused the aircraft to snap roll to an inverted attitude at low altitude. The unusual attitude and loss of engine power resulted in the crash." ## Aircraft - Registration: [N36SV](https://openairdocs.org/deregistered/N36SV-2018-01-23), registration cancelled 2018-01-23, S/N TE-848, built 1971 (OpenAirDocs) - Reported make and model: BEECH E55 - Registry model: [Beech E-55](https://openairdocs.org/model/beech-e-55) (registry code 1152732) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TE848 - Airframe hours: 3350 - Engines: CONTINENTAL IO-520-C3 285 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Evergreen Air, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 9, 1995, 200 hours before - Departed: HEF - Destination: GAI, GAITHERSBURG, MD - Flight plan: IFR - Airport: HEF, Manassas Regional, runway 16L, 5,700 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 450 total, 80 in this make and model, 450 as pilot in command, 30 in the last 90 days, 10 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 7 knots, gusting 15 - Visibility: 5 statute miles - Lowest ceiling: 4,000 ft overcast - Temperature: 39 °F, dew point 36 °F - Altimeter: 30.00 inHg ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19951113036479A](https://openairdocs.org/incident/19951113036479A), Nov 13, 1995: Beech E55, Manassas, VA, Destroyed. Lost left engine on climbout. Snap rolled. Impacted on wing and cartwheeled. Selected aux tank. Didn't switch back From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.