CEN09LA227

NTSB accident investigation · Beech A36 · Laredo, TX · March 21, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
March 21, 2009, 16:30 local (21:30 UTC)
Place
Laredo, TX
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N8120RBeech A36
Defining event
Approach-VFR pattern downwind: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report October 19, 2009
Report
Approved by Office Director
NTSB office
Central Region
Parties
Hawker Beechcraft Company, FAA FSDO
FAA report
20090321005009A
Case key
73535

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

On this page

Probable cause

The certificated flight instructor's improper fuel management resulting in an engine failure due to fuel starvation. Contributing to the accident was the flight instructor's failure to properly complete the restart checklist.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech A36: 22 casesAll aircraft: 1,695 casesProbable cause
Action: incomplete actionPersonnel issues › Action/decision · Instructor/check pilotBeech A36: 1 caseAll aircraft: 105 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · Instructor/check pilotBeech A36: 8 casesAll aircraft: 336 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

While in the traffic pattern, the fuel in the airplane's left wing tank was depleted resulting in a complete loss of engine power. The certified flight instructor (CFI) directed the non-rated passenger sitting in the left seat to position the fuel selector valve to the right tank. The CFI did not accomplish the restart checklist in accordance with the pilot's operating handbook. Engine power was not restored, and the CFI elected to perform a forced landing to an apartment parking lot. The airplane was substantially damaged during the gear-up landing. An examination of the airframe, engine, and fuel selector valve failed to reveal any pre-impact anomaly which would have precluded a restart of the engine.

Factual narrative

On March 21, 2009, approximately 1630 central daylight time, a Beech A36, N8120R, was substantially damaged during a collision with terrain and vehicles following a loss of engine power and subsequent forced landing at Laredo, Texas. The local flight departed Laredo International Airport (LRD), Laredo, Texas, approximately 1530 and remained in the traffic pattern. The airplane was owned and operated by Yvoden Inc. The certified flight instructor (CFI) sustained minor injuries and the non-rated passenger/owner received serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. According to the CFI, while in the traffic pattern, about 800 feet above ground level, the engine "hesitated" and the CFI directed the non-rated passenger, who was sitting in the left seat, to change the fuel selector valve to the right tank which contained an estimated 25 gallons of fuel. The engine stopped producing power and when the pilots could not restart the engine, the CFI performed a forced landing to an apartment parking lot. During the forced landing, the airplane struck two vehicles before coming to rest in the upright position. Both wings sustained multiple impacts and the engine was torn away at the firewall. Both wing fuel tanks were breeched. An on-scene examination of the airplane by a Federal Aviation Administration (FAA) inspector failed to reveal any airframe or engine anomaly. Damage to the fuel tanks prevented a determination of fuel remaining. The airplane's fuel selector was removed and shipped to Wichita, Kansas, for an examination at Hawker Beechcraft's facilities. Testing of the fuel selector was accomplished by inspectors from the FAA and technical representatives from Hawker Beechcraft. When the acceptance test procedure was conducted, the fuel selector seeped fuel up the selector shaft when pressure was applied and the selector was in the off-position. The valve did not leak when a tank position was selected. Valve selector detents did not have a "crisp" feel, however, all detents were readily identifiable, and the selector had no obstruction to movement. When disassembled and inspected, the shaft seal was found to be intact, but the shaft was found to be worn. Despite the anomaly of seeping fuel in the "off" position when pressure was applied, the fuel selector operated normally and would have directed fuel from the selected tank to the engine. In an interview with FAA inspectors, the pilot reported that he did not use the boost pump during the restart attempt. A review of the pilot's operating handbook (POH) revealed that the second step of the Engine Failure: After Liftoff and In Flight, is "Auxiliary Fuel Pump - ON." In addition, the non-rated passenger reported that the CFI switched the tanks several times to ensure that the fuel selector was seated in the right fuel tank detent.

Aircraft

Registration
N8120R
Reported as
Beech A36
Category
Airplane
Serial number
E-583
Engine
Cont Motor IO-550B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Yvoden Inc
Registered owner
Yvoden Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 5, 2008
Departed
LRD · Laredo, TX
Destination
LRD · Laredo, TX
Airport
LRD · Laredo International, runway 17L, 7,830 × 150 ft, asphalt

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
Flight instructor
Age
47
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
December 6, 2007
Seat
Right
Flight hours
3,340 total · 19 in this make and model · 3,055 as pilot in command · 47 in the last 90 days · 13 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 17 knots, gusting 23
Visibility
9 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
LRD

Docket · 6

The files NTSB released with the investigation on August 26, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 MB in all.

FAA reports on this event · 1

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