CEN12FA210

NTSB accident investigation · Beech E-55 · Broken Bow, NE · March 28, 2012

Accident · FatalField investigationFinal report
Date
March 28, 2012, 13:13 local (18:13 UTC)
Place
Broken Bow, NE
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1567WBeech E-55
Defining event
Approach-VFR pattern final: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report November 7, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Inc., Hawker Beechcraft Corporation, FAA -- Flight Standards
FAA report
20120328004879A
Case key
83241

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 pilot’s failure to maintain airspeed and subsequent loss of airplane control during a single-engine landing approach. Contributing to the accident was the pilot's improper fuel management during cruise flight, which resulted in an initial loss of power in both engines and the subsequent single-engine approach after power was restored on only one engine.

Findings · 4

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech E-55: 4 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech E-55: 1 caseAll aircraft: 1,681 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · PilotBeech E-55: 1 caseAll aircraft: 397 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech E-55: 1 caseAll aircraft: 1,695 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

The pilot said that he noted an imbalance between the left and right main fuel tanks during cruise flight. He attempted to correct the imbalance by placing the left fuel selector in the crossfeed position so that both engines would receive fuel from the right main fuel tank. About 15 minutes after the pilot selected the crossfeed position, both engines lost power. When the pilot reset the left and right fuel selectors to the left main and the right auxiliary fuel tanks, respectively, the left engine regained power and the right engine began "surging." The pilot decided not to shut down the right engine and diverted to the nearest suitable airport. During final approach, the right engine lost power completely, and the airspeed decayed until it approached the airplane’s minimum control airspeed. When the airplane drifted right of the runway centerline, the pilot reduced power on the left engine in an attempt to maintain control. The airplane impacted an open field near the runway and a postimpact fire ensued. Postaccident examination revealed no airframe or engine anomalies consistent with a preimpact mechanical failure or malfunction. Both fuel selectors were positioned to their respective main fuel tanks. The pilot stated that the airplane was fully fueled before departure. The airplane fuel system was composed of two 37-gallon main fuel tanks and two 31-gallon auxiliary fuel tanks. The pilot stated that he had not used any of the fuel in the auxiliary tanks before the loss of engine power. The pilot's operating handbook noted that the crossfeed system was not to be used to transfer fuel from one tank to another or to balance fuel during flight. The simultaneous loss of engine power while both engines were receiving fuel from one fuel tank, the restoration of power on the left engine after switching fuel tanks, operation at or near the fuel endurance limit for the right main fuel tank, and the lack of anomalies identified during the engine exams are consistent with exhaustion of fuel in the right main tank.

Factual narrative

HISTORY OF FLIGHT On March 28, 2012, about 1313 central daylight time, a Beech E-55 (Baron), N1567W, was substantially damaged when it impacted terrain while on approach to the Broken Bow Municipal Airport (BBW), Broken Bow, Nebraska. The pilot was seriously injured and the sole passenger was fatally injured. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight originated from Dickinson – Theodore Roosevelt Regional Airport (DIK) at 1053. The intended destination was Russell Municipal Airport (RSL), Russell, Kansas. After takeoff, the flight climbed to 11,500 feet mean sea level (msl) en route to RSL. The pilot obtained visual flight rules flight following services from Denver Air Route Traffic Control Center. At 1303, the pilot informed the Denver Center controller of an engine failure. At that time, the flight was about 20 miles west-northwest of BBW. The pilot altered course and diverted to BBW. The final radar data point, recorded at 1313:41 (hhmm:ss), was located 1.53 miles northwest of BBW, with an associated altitude of 3,400 feet msl. The pilot stated that during cruise flight the left main fuel tank indicated a lower quantity than the right main fuel tank. In an effort to balance the fuel levels, he elected to set the left fuel selector to crossfeed. About 15 minutes after switching tanks, the right engine lost power, followed shortly by the left engine. Power was restored to the left engine about 10 seconds after resetting the fuel selector to the left main tank. The pilot reportedly set the right fuel selector to the right auxiliary tank after the loss of power. The right engine was "surging," so he did not shut it down. The pilot reported that he was unable to maintain altitude with the left engine at full power. After establishing visual contact with BBW, the pilot lowered the landing gear and selected approach flaps in preparation for landing. Full rudder input was required to maintain directional control. The right engine lost power completely when the airplane was on a 1-1/2 mile final; about 900 feet agl. The pilot did not feather the right propeller, thinking he was too close to landing to get the engine secured. The airspeed was approaching minimum control airspeed at that time. The pilot reported that the airplane drifted about 100 yards west (right) of the runway centerline and he reduced power on the left engine in an attempt to maintain control. The airplane impacted an open field about 455 feet west-southwest of the BBW runway 14 threshold. The airplane came to rest inverted about 120 feet southwest of the initial impact point. A postimpact fire ensued. PERSONNEL INFORMATION The accident pilot held a private pilot certificate with single and multi-engine land airplane, and instrument airplane ratings. He was issued a thirdclass airman medical certificate on June 4, 2009, with no limitations. The pilot passed the practical test for the addition of a multi-engine land airplane rating to his private pilot certificate on March 22, 2012; 6 days prior to the accident. On his application for that rating, the pilot reported a total flight time of 257 hours, with 15.3 hours in Beech E-55 airplanes. He had reportedly accumulated an additional 7 hours in the Beech E-55 prior to the accident flight. His flight time within the previous 90 days was about 34 hours. The pilot stated that his logbook was in the airplane at the time of the accident. (The logbook was not recovered during the on-scene examination and was presumably destroyed.) AIRCRAFT INFORMATION The accident airplane was a Beech E-55 Baron, serial number TE-862. It was a six-place, twin-engine airplane, configured with a retractable, tri-cycle landing gear. The airplane was powered by two 285-horsepower Continental IO-520-CB engines, serial numbers 282491-R (left) and 244387-R (right). The most recent annual inspection was completed on September 15, 2011, at a total airframe time of 3,691 hours. The left and right engines had accumulated 768 and 1,020 hours, respectively, since a factory remanufacture. Records indicated that the accident pilot purchased the airplane on January 12, 2012. The pilot stated that the airplane maintenance logbooks were in the airplane at the time of the accident. As a result, a detailed review of the airplane maintenance history was not possible. (The logbooks were not recovered during the on-scene examination and are presumably destroyed.) METEOROLOGICAL INFORMATION Weather conditions recorded by the BBW Automated Surface Observing System (ASOS), at 1253, were: Wind from 150 degrees at 13 knots, gusting to 20 knots; 10 miles visibility; clear sky; temperature 20 degrees Celsius; dew point 2 degrees Celsius; and altimeter 29.98 inches of mercury. At 1353, weather conditions were: Wind from 150 degrees at 11 knots, gusting to 21 knots; 10 miles visibility; clear sky; temperature 22 degrees Celsius; dew point 2 degrees Celsius; and altimeter 29.96 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted an open field about 455 feet west-southwest of the runway 14 threshold at BBW. The wreckage path was about 170 feet long and was oriented on a bearing of about 210 degrees magnetic. The initial impact ground scar was 7 feet long by 2 feet wide by 1 foot deep. A second ground scar was located approximately 4 feet from the initial scar and measured approximately 33 feet long, up to 3 feet wide and 2 feet deep. Two additional ground scars were located along the debris path prior to the main wreckage. Two areas of scorched terrain were observed at the accident site. The first was approximately 60 feet long by 25 feet wide, and located between the final ground scar and the main wreckage. The main wreckage consisted of the fuselage, empennage, and left engine. The second scorchedarea extended about 26 feet west of the main wreckage; adjacent to the right wing and fuselage nose. The second scorched area was about 12 feet wide. The airframe came to rest inverted, bearing about 360 degrees. The empennage was separated and located adjacent to the fuselage; although, it was rotated about 150 degrees clockwise. The empennage was oriented vertically, with the rudder and elevators contacting the ground. Significant portions of the airframe were consumed by the postimpact fire. The outboard 3 feet of the right wing was separated from the remainder of the wing structure. It came to rest about 63 feet southeast of the initial impact ground scar. The wing tip did not exhibit any damage due to the postimpact fire. Both of the main landing gear assemblies were in the extended positions. The nose structure surrounding the nose landing gear was consumed by the postimpact fire. The position of the landing gear motor and actuator linkage corresponded to the extended gear positions. The left engine was separated from the airframe and located about 2 feet from the engine pylon (firewall). The right engine was separated completely from the airframe. It came to rest about 46 feet southeast of the main wreckage. The left engine was discolored consistent with exposure to the postimpact fire. The right engine did not appear to exhibit any damage due to the postimpact fire. Both propeller assemblies remained attached to the engines. Damage to the individual propeller blades appeared consistent with impact forces and postimpact thermal exposure. The flight control surfaces were intact and remained attached to the airframe, with the exception of the left aileron. Portions of the left aileron were consumed by the postimpact fire. Flight control cable continuity was confirmed. The flap flexdrive cables were continuous from the flap motor to both actuators. The left flap actuator extension was consistent with a 30-degree (full down) flap deflection. The right flap actuator was damaged to an extent that the right flap position could not be verified. Both engine fuel selector valves sustained thermal damage consistent with the postimpact fire. No anomalies consistent with a failure of either valve assembly were observed. Both valve assemblies were positioned to their respective main fuel tanks at the time of the postaccident examination. Partial teardown examination of the left engine did not reveal any preimpact anomalies. An operational test run was conducted on the right engine under direct supervision of the NTSB. The right engine operated smoothly throughout the full throttle range during the operational test run. The postaccident examinations of the airframe and engines did not reveal any anomalies consistent with a preimpact failure or malfunction. ADDITIONAL INFORMATION The pilot stated that the airplane was fully fueled (topped off) prior to departing DIK. Fixed base operator (FBO) records indicated that the accident pilot purchased 72.9gallons of fuel at DIK the day prior to the accident flight. The accident airplane had a maximum usable fuel capacity of 136 gallons distributed in four fuel tanks. It was equipped with a 37-gallon (usable) main fuel tank and a 31-gallon (usable) auxiliary fuel tank in each wing. Fuel quantity was indicated for either the main fuel tanks or the auxiliary fuel tanks in the respective wings. A two-position selector switch determined the tanks, either main or auxiliary, to which the indication is associated. During normal operations, each engine draws fuel from the respective main or auxiliary fuel tank. However, the left and right fuel tanks are interconnected by crossfeed fuel lines. Crossfeed operation would allow the entire fuel supply of any fuel tank to be consumed by either engine. For example, with the left fuel selector in the crossfeed position, the left engine will draw fuel from the right main or auxiliary fuel tank, as set by the right fuel selector. The pilot's operating handbook noted that the crossfeed system was not to be used to transfer fuel from one tank to another or to balance fuel during flight. An estimate of fuel consumption for the entire accident flight calculated that about 34.3 gallons of fuel was consumed from the right main fuel tank. About 30.0 gallons were consumed from the left main fuel tank. The pilot stated that he had not burned fuel from either auxiliary fuel tank prior to the loss of engine power.

Aircraft

Registration
N1567W
Reported as
Beech E-55
Category
Airplane
Serial number
TE-862
Airframe hours
3,691
Engines
Cont Motor IO 520 SERIES, 285 horsepower, reciprocatingCont Motor IO-520-CB, 285 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 15, 2011
Departed
DIK · Dickinson, ND
Destination
RSL · Russell, KS
Flight plan
VFR
Airport
BBW · Broken Bow Municipal, runway 14, 4,203 × 75 ft, concrete

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
33
Injuries
Serious
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
March 22, 2012
Seat
Left
Flight hours
257 total · 23 in this make and model · 34 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 13 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 36 °F
Altimeter
29.97 inHg
Observed at
BBW

Docket · 29

The files NTSB released with the investigation on September 21, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.4 MB in all.

Interview Record -- PilotItem 1 · .PDF · 53 KBFAA Interview Record -- PilotItem 2 · .PDF · 249 KBWitness Statements -- Nebraska National Guard Helicopter CrewItem 3 · .PDF · 434 KBPlot of ATC Radar Track DataItem 4 · .PDF · 563 KBTranscript of Flight Service CommunicationsItem 5 · .PDF · 96 KBSummary of ATC ContactItem 6 · .PDF · 157 KBTranscript of ATC CommunicationsItem 7 · .PDF · 644 KBSummary of On-Scene ExaminationItem 8 · .PDF · 59 KBOperational Test Report -- Right EngineItem 9 · .PDF · 1.2 MBDiagram of Accident Site (provided by Hawker Beechcraft)Item 10 · .PDF · 81 KBAirplane Maintenance/Inspection DocumentationItem 11 · .PDF · 76 KBPilot's Operating Handbook -- ExcerptsItem 12 · .PDF · 654 KBFueling ReceiptItem 13 · .PDF · 35 KBEstimate of Fuel ConsumptionItem 14 · .PDF · 28 KBConversation Record -- Designated Pilot ExaminerItem 15 · .PDF · 54 KBWeather Observations -- Broken BowItem 16 · .PDF · 36 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 17 · .PDF · 96 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 861 KBPhoto 1 -- Accident SiteItem 19 · .PDF · 451 KBPhoto 2 -- Accident SiteItem 20 · .PDF · 483 KBPhoto 3 -- Main WreckageItem 21 · .PDF · 547 KBPhoto 4 -- Main WreckageItem 22 · .PDF · 436 KBPhoto 5 -- Main WreckageItem 23 · .PDF · 587 KBPhoto 6 -- EmpennageItem 24 · .PDF · 440 KBPhoto 7 -- Right EngineItem 25 · .PDF · 558 KBPhoto 8 -- Left EngineItem 26 · .PDF · 347 KBPhoto 9 -- Left PropellerItem 27 · .PDF · 342 KBPhoto 10 -- Right EngineItem 28 · .PDF · 459 KBPhoto 11 -- Right PropellerItem 29 · .PDF · 367 KB

FAA reports on this event · 1

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