# NTSB CEN10LA005: Beech A36, N991PP, Refugio, TX, October 2, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: October 2, 2009, 13:10 local (18:10 UTC) - Place: Refugio, TX - Coordinates: 28.230581, -97.320907 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.2306&lon=-97.3209&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 1 minor, 2 uninjured - Status: Completed, report March 3, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO, Teledyne Continential Motors - NTSB case key (mKey): 74855 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74855/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74855 - Page: https://openairdocs.org/ntsb/CEN10LA005 ## Probable cause A total loss of engine power due to fuel starvation as a result of the pilot's improper fuel management. Contributing to the accident was the pilot's failure to follow the correct engine restart checklist. ## 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 A36, 22 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151604), [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 · Pilot (probable cause); cases with it: [Beech A36, 17 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151604), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 8 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1151604), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech A36, 15 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151604), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During a cross-country flight the pilot tracked his fuel usage by watching the engine analyzer; however, about 180 miles from his destination airport the engine lost power and the pilot performed a forced landing, resulting in substantial to the airplane. During the descent the pilot unsuccessfully tried to restart the engine by switching the fuel selector between the right and left fuel tanks. An on-site examination of the airplane revealed that the that the airplane's left wing fuel tank contained about 2 cups of fuel and when the right wing fuel cap was removed, fuel would spill from the tank. An additional examination of the fuel selector, airframe, and an engine test run failed to reveal a preimpact anomaly that would have precluded a restart of the engine. The pilot later added that while trying to restart the engine he did not turn on the electric-driven fuel pump. Additionally, he noted that the checklist that he carried in the aircraft failed to mention the electric-driven fuel pump; however, he noted that the pilot's operating handbook (POH) did mention the electric pump. ## Factual narrative On October 2, 2009, approximately 1310 central daylight time, a single-engine, Beechcraft A-36 airplane, N991PP, was substantially damaged during a forced landing following a loss of engine power, near Refugio, Texas. The private pilot received minor injuries and the two passengers were not injured. The airplane was registered and operated by a private individual. The approximately 676 nautical-mile cross-country flight originated from the New Century AirCenter Airport (KIXD), Olathe, Kansas under visual meteorological conditions en route to the Corpus Christi International Airport (KCRP) Corpus Christi, Texas. About 180 miles from the destination airport, the pilot activated an instrument flight plan for the 14 Code of Federal Regulations Part 91 flight. According to the pilot, he departed KIXD with the fuel tanks "topped off", and that he managed the fuel en route by using the aircraft's engine analyzer. During the flight he switched between the left and right fuel tanks and recorded how much fuel was consumed. About four hours into the flight, the engine began to "sputter and lose power". The pilot asked for, and received a heading to the nearest airport from air traffic control. During the decent, the piloted switched from the right wing fuel tank to the left wing fuel tank, and then back to the right tank. However, he was unable to get the engine to restart. Unable to make the airport, the pilot elected to conduct an emergency landing in a field near the airport. The airplane collided with a bush before impacting terrain; the airplane then slid to a stop. The pilot and passengers were able to exit the airplane unassisted. The pilot added later, that while trying to restart the engine, he did not turn on the electric driven fuel pump. Additionally, he noted the checklist that he carried in the aircraft failed to mention the electric driven fuel pump; however, he noted that the pilot's operating handbook (POH) did mention the electric pump. The Federal Aviation Administration (FAA) Inspector, who responded to the accident site, reported that the airplane's right gear had been forced through the wing, and that the airplane sustained substantial damaged during the forced landing. He added that the airplane's left wing fuel tank contained, "2 cups of fuel" and when the fuel cap from the right wing was removed, fuel would spill from the tank. The wreckage was transported to a secure facility near Lancaster, Texas, for further examination. An examination was conducted by the NTSB IIC with a technical representative from Teledyne Continental Motors, on 23 October, 2009. The engine, with 81 hours since major overhaul, remained attached to the airframe. The engine/fuselage was placed on a trailer without the wings, which had been removed for transport. A fuel can was connected to the airplane's fuel system on the right side wing root. The airplane's propeller, which had been damaged in the accident, was replaced with a test propeller. Prior tostarting the engine, a visual engine inspection was conducted and no abnormalities were discovered. Additionally, to check for proper operation, the fuel selector valve was turned to the left and right positions. The engine was then started and ran for several minutes at various (idle to full) power settings. During the tests, the engine appeared to produce full power. ## Aircraft - Registration: [N991PP](https://openairdocs.org/deregistered/N991PP-2011-10-05), registration cancelled 2011-10-05, S/N E-914, built 1976 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-914 - Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Aero Mark Jm LLC - Registered owner: Aero Mark Jm LLC - Airworthiness certificate: Standard, Normal - Departed: KIXD, New Century Air, KS - Destination: KCRP, Corpus Christi, TX - Flight plan: VFR/IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review January 20, 2008; seat: left; flight hours: 1,142 total, 448 in this make and model, 860 as pilot in command, 26 in the last 90 days, 11 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: 12,000 ft overcast - Temperature: 82 °F, dew point 72 °F - Altimeter: 29.86 inHg - Observed at: KRKP, 17 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 (OpenAirDocs). - [Accident 20091002020099A](https://openairdocs.org/incident/20091002020099A), Oct 2, 2009: Beech A36, Refugio, TX, Substantial damage. Aircraft lost power on a flight from olathe, KS, (ixd), direct corpus christi, TX, (crp). The aircraft attemtped to make an emergency landing at Refugio, TX,… ## Docket (5 files) The files NTSB released with the investigation on November 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74855. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321336&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Reports and Records (item 2, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321338&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321346&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321539&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo: N991PP Engine Run (item 5, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321540&FileExtension=.PDF&FileName=Photo%3A%20N991PP%20Engine%20Run-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.