CEN12LA134

NTSB accident investigation · Aero Commander 500-B · Bartlesville, OK · January 14, 2012

Accident · Minor injuriesLimited investigationFinal report
Date
January 13, 2012, 19:30 local (Jan 14, 2012, 01:30 UTC)
Place
Bartlesville, OK
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N524HWAero Commander 500-B
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Night
Status
Completed · report December 19, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20120113001889A
Case key
82688

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 total loss of engine power due to fuel exhaustion and the pilot’s inadequate preflight inspection, which did not correctly identify the airplane’s fuel quantity before departure.

Findings · 2

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.

Inspection: preflight inspectionPersonnel issues › Task performance · PilotAero Commander 500-B: 2 casesAll aircraft: 551 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelAero Commander 500-B: 5 casesAll 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 was en route on a positioning flight when the airplane’s right engine surged and experienced a partial loss of power. He adjusted the power and fuel mixture controls; however, a few seconds later, the engine surged again. The pilot noted that the fuel flow gauge was below 90 pounds, so he turned the right fuel pump on. The pilot then felt a surge on the left engine, so he performed the same actions he as did for the right engine. He believed that he had some sort of fuel starvation problem. The pilot then turned to an alternate airport, at which time both engines lost total power. The airplane impacted trees and terrain about 1.5 miles from the airport. The left side fuel tank was breached during the accident; however, there was no indication of a fuel leak, and about a gallon of fuel was recovered from the airplane during the wreckage retrieval. The company’s route coordinator reported that prior to the accident flight, the pilot checked the fuel gauge and said the airplane had 120 gallons of fuel. A review of the airplane’s flight history revealed that, following the flight immediately before the accident flight, the airplane was left with approximately 50 gallons of fuel on board; there was no record of the airplane having been refueled after that flight. Another company pilot reported the airplane fuel gauge had a unique trait in that, after the airplane’s electrical power has been turned off, the gauge will rise 40 to 60 gallons before returning to zero. When the master switch was turned to the battery position during an examination of another airplane belonging to the operator, the fuel gauge indicated approximately 100 gallons of fuel; however, when the master switch was turned to the off position, the fuel quantity on the gauge rose to 120 gallons, before dropping off scale, past empty. Additionally, the fuel cap was removed and fuel could be seen in the tank, but there was no way to visually verify the quantity of fuel in the tank.

Factual narrative

On January 13, 2012, about 1930 central standard time, a twin-engine Aero Commander 500-B airplane, N524HW, experienced a loss of engine power during cruise flight near Bartlesville, Oklahoma. The airline transport rated pilot, sole occupant, received only minor injuries during a forced landing and the airplane was substantially damaged. The airplane was owned and operated by Central Airlines, Inc. Fairway, Kansas, under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Night visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from the Charles B. Wheeler Downtown Airport (KMKC), Kansas City, Missouri, about 1810, en route to the Cushing Municipal Airport (KCUH), Cushing, Oklahoma. The pilot reported that he was at an altitude of 8,000 feet, just southwest of Bartlesville, when the right engine surged and lost partial power. He adjusted the power and mixture controls, which seemed to correct the problem; however, a few seconds later the engine surged again. The pilot noted that the fuel flow gauge was below 90 pounds, so he turned the right fuel boost pump on. The pilot added he then got a surge on the left engine, so he performed the same actions he did for the right engine and felt that he had some sort of fuel starvation problem. The pilot contacted air traffic control and started his turn to the Bartlesville airport (KBVO), at which time, both engines lost total power. The airplane impacted trees and terrain, about 1.5 miles from the airport. The pilot added that before he secured the airplane and turned the master battery switch off, the fuel gauge was still indicating 100 gallons. The responding Federal Aviation Administration (FAA) inspector reported that the airplane received heavy damage during the collision with trees and terrain. The on-site examination of the airplane revealed that the airplane was sitting on its belly, with the main landing gear partly extended. The fuselage just aft of the wings was severely damaged, both the left and right wings were damaged, and the nose of the aircraft was damaged. A hole on the underside of the left wing root exposed the fuel tank bladder. The bladder appeared to have been breached; there was no evidence of a fuel leak on the ground, adjacent the wing. The inspector added that before moving the airplane wreckage, he turned on the airplane’s battery power and observed the fuel gauge. The fuel gauge moved from below “E” to just above “E”, when power was applied. The inspector noted that about a gallon of fuel was captured from the aircraft, prior to the wreckage retrieval. A company check pilot flew the aircraft on its previous flight on 11 January. The check pilot reported he ferried the airplane from Chicago back to KMKC, arriving with 50 gallons of fuel remaining. He added there were no mechanical problems with the airplane and that he verbally passed the airplane’s fuel statusto dispatch. The pilot also reported that the airplane fuel gauge had a unique trait; after the airplane’s electrical power has been turned off, the gauge will rise 40 to 60 gallons before returning to zero. The company’s director of operations stated that the fuel consumption on the Aero Commander is about 15 gallons per hour, per engine. Prior to the accident flight, the airplane was moved from the ramp to the company’s hangar; however, the pilot who taxied the airplane could not recall the amount of fuel on the airplane. The company’s route coordinator reported that he met the pilot on the day of accident flight and gave him the credit card for fuel and a ride to the hangar. The coordinator stated that he stayed by the airplane’s door, while the pilot sat in the pilot’s seat, turned on the master switch and checked the fuel. The coordinator stated that the pilot said the airplane had “120 gallons of fuel”. The FAA inspector examined a similar airplane to the accident airplane, at the company’s facility in Cushing, Oklahoma. The inspector noted that when the master switch was turned to the battery position, the fuel gauge indicated approximately 100 gallons of fuel; however, when the master switch was turned to the off position, the fuel quantity on the gauge rose to 120 gallons, before dropping off scale empty. The inspector also removed the fuel cap and that he could see fuel in the tank, but there was no way of verifying how much fuel was in the tank. A review of the operator’s “Preflight Visual Inspection of the airplane – Aero Commander 500 B/U” checklist; included “fuel quantity – check level and security of fuel cap”; however, a specific method to check fuel quantity was not specified.

Aircraft

Registration
N524HW
Reported as
Aero Commander 500-B
Category
Airplane
Serial number
1533-191
Engines
Lycoming TI0-540 SER, 310 horsepower, reciprocatingLycoming TI0-540 SER, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Central Airlines Inc
Registered owner
Central Airlines Inc
Departed
KMKC · Kansas City, MO
Destination
KCUH · Cushing, OK
Flight plan
Unknown

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
52
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 26, 2011
Seat
Left
Flight hours
8,487 total · 3,477 in this make and model · 8,425 as pilot in command · 139 in the last 90 days · 39 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Visibility
10 statute miles
Lowest ceiling
None
Temperature
25 °F, dew point 18 °F
Altimeter
30.12 inHg
Observed at
KBVO

Docket · 5

The files NTSB released with the investigation on October 22, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 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.