# NTSB CEN09LA274: Beech 35-C33, N528BM, Addison, TX, May 4, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 3, 2009, 21:06 local (May 4, 2009, 02:06 UTC) - Place: Addison, TX - Coordinates: 32.968612, -96.836387 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.9686&lon=-96.8364&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Teledyne Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 73768 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA274 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73768/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73768 - Page: https://openairdocs.org/ntsb/CEN09LA274 ## Probable cause A loss of engine power in flight due to fuel starvation as a result of the pilots' inadequate fuel management. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech 35-C33, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151408), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Beech 35-C33, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151408), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech 35-C33, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=1151408), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Initial climb: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Beech 35-C33, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=1151408), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech 35-C33, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151408), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech 35-C33, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151408), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The two commercial pilots (one of which was the owner) flew to the accident location and dropped off a passenger. Prior to the first flight the owner pilot had checked the fuel levels and determined there was enough fuel to make their desired flights. Neither pilot ensured the fuel selector was selecting the fullest tank prior to the second takeoff. On departure and about 200 feet above the ground the engine began sputtering and then lost power. The pilots switched fuel tanks in-flight, but the engine did not restart. The airplane landed short of the runway, resulting in substantial damage to the airplane and serious injuries to both pilots. Examination of the airplane revealed the right main tank was empty and the fuel selector was selected to the left main tank. ## Factual narrative On May 3, 2009, about 2106 central daylight time, a Beech 35-C33 airplane, N528BM, was substantially damaged during a forced landing following a loss of engine power after takeoff from Addison Airport (ADS), Addison, Texas. Both commercial pilots were seriously injured. The flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The repositioning flight was originating from ADS, and was en-route to Hicks Airfield (T67), Fort Worth, Texas. Night, visual meteorological conditions prevailed at the time of the accident. The pilot was flying in the left seat to build high performance pilot in command (PIC) time. His first flight in the airplane was the afternoon of the accident, when he and the airplane owner, who was also a commercial pilot, flew the owner’s son from T67 to ADS. The pilot stated he was unfamiliar with the airplane. The owner-pilot, who was in the right seat, stated he had checked the fuel before flying to ADS and determined each main tank had between 15 and 20 gallons of fuel and the fuel selector was on the right main tank. The airplane was on departure from initial takeoff and about 200 feet above the ground when the engine started sputtering. The owner-pilot immediately suspected the problem was that the fuel selector was still on the right main tank and it should have been switched to the left main tank. He reached for the fuel selector switch, which was located under the pilot’s left leg, but he could not reach it. He then took control of the airplane and the pilot switched the fuel selector. The pilot stated he could not recall which tank it was on. The owner-pilot then attempted to return to ADS and land, but the airplane landed short of the runway on airport property. The owner-pilot stated on the Accident/Incident Report (NTSB Form 6120.1) “I believe we took-off on the [right main fuel tank] and ran it empty. There [was not] time for the fuel in the [left main fuel tank] to restart the engine before we hit the ground. Other factors were that [the pilot] was unfamiliar with the airplane and I [was not] double checking him.” “The aircraft hit the ground before I could see [the ground].” Examination of the airplane revealed the left main landing gear strut was sheared off and pushed up through the left wing. The left horizontal stabilizer was damaged and the fuselage was partially buckled. Investigators on scene found the left wing tank was intact and contained approximately five to six gallons of fuel and the right wing tank was empty. The fuel selector was found in the left tank position. A post accident engine inspection revealed the fuel inlet line and fuel vapor line were both dry and did not contain any fuel. Fuel was observed in the fuel manifold. The inspection did not reveal any abnormalities that would have prevented normal operation. ## Aircraft - Registration: [N528BM](https://openairdocs.org/deregistered/N528BM-2009-06-29), registration cancelled 2009-06-29, S/N CD-1056, built 1966 (OpenAirDocs) - Reported make and model: BEECH 35-C33 - Registry model: [Beech 35-C33](https://openairdocs.org/model/beech-35-c33) (registry code 1151408) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CD-1056 - Airframe hours: 577 - Engines: CONT MOTOR IO-520-BB 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Martin Bryan S - Registered owner: Martin Bryan S - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Unknown, January 16, 2009 - Departed: ADS, Addison, TX - Destination: T67, Hicks Airfield, TX - Airport: ADS, Addison Airport, runway 33, 7,202 × 100 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Co-pilot; age 40; injuries: serious; private, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 8, 2008; seat: right; flight hours: 1,020 total, 816 in this make and model, 923 as pilot in command, 60 in the last 90 days, 16 in the last 30 days, 0 in the last 24 hours - Pilot; age 34; injuries: serious; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review September 23, 2008; seat: left; flight hours: 905 total, 1 in this make and model, 858 as pilot in command, 419 in the last 90 days, 144 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 320° at 8 knots - Visibility: 13 statute miles - Lowest ceiling: 2,900 ft overcast - Temperature: 61 °F, dew point 55 °F - Altimeter: 29.94 inHg - Observed at: ADS ## 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 20090503006399A](https://openairdocs.org/incident/20090503006399A), May 3, 2009: Beech 35C33, Dallas, TX, Substantial damage. On may 3, 2009, about 2100 central daylight time (CDT), a debonair BE-35-C33, N528BM, crashed on airport property at Addison Airport, Addison Texas (kads).… ## Docket (4 files) The files NTSB released with the investigation on January 7, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73768. 1.5 MB in all. - Pilot Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 591 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321831&FileExtension=.PDF&FileName=Pilot%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 603 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321832&FileExtension=.PDF&FileName=Operator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Photo 1 - Wreckage (item 3, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321833&FileExtension=.PDF&FileName=Photo%201%20-%20Wreckage-Master.PDF - Photo 2 - Wreckage (item 4, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321834&FileExtension=.PDF&FileName=Photo%202%20-%20Wreckage-Master.PDF 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.