# NTSB CEN13LA109: Beech A23, N3573R, Grand Isle, NE, December 18, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 18, 2012, 14:49 local (20:49 UTC) - Place: Grand Isle, NE - Coordinates: 40.95861, -98.289443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.9586&lon=-98.2894&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 11, 2013 - Report: Approved by Office Director - NTSB office: Central Region - NTSB case key (mKey): 85849 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA109 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85849/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85849 - Page: https://openairdocs.org/ntsb/CEN13LA109 ## Probable cause The student pilot's inadequate fuel management due to distraction by airport traffic, which resulted in a loss of engine power due to fuel starvation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=1151204), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Training: recent instruct/training recvd](https://openairdocs.org/ntsb-findings/02031525): Personnel issues › Experience/knowledge · Student/instructed pilot; cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02031525/cases.md?model=1151204), [All aircraft, 9 cases](https://openairdocs.org/ntsb-findings/02031525/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151204), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=1151204), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Student/instructed pilot (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=1151204), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech A23, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151204), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis The student pilot reported that he completed two full-stop landings without incident. He stated that, during the crosswind leg of the traffic pattern for the third landing, the turn was “rushed” due to the traffic. While on the downwind leg, the tower controller advised the student of traffic, and the leg was extended. The student stated that, during his prelanding instrument check, he noted that the selected right fuel tank was empty and that he then selected the left fuel tank, which indicated that 3/8 of a tank of fuel was remaining. Shortly thereafter, the engine lost power, and the student pilot landed it to a field on airport property. The student pilot stated that, immediately after the forced landing, he started the airplane and taxied back to the ramp with the left fuel tank still selected. A mechanic inspected the engine fuel injection system and found no blockage or contamination in the distribution manifold or the fuel injector nozzles. He also drained the remaining fuel from both fuel tanks and found that the right fuel tank had 1.5 quarts of fuel remaining and that the left fuel tank had 19.75 gallons of fuel remaining. Therefore, it is likely that the student pilot was distracted by airport traffic and did not switch from the empty fuel tank to the fuel tank with fuel remaining in a timely manner, thus starving the engine of fuel. Given the proximity to the ground, the student pilot did not have time to attempt to restart the engine. ## Factual narrative On December 18, 2012, about 1449 central daylight time a Beechcraft A23 Musketeer, N3573R, performed a forced-landing after a loss of engine power. The solo student pilot received no injuries. The aircraft received substantial damage to the left wing spar. The aircraft was registered to, and operated by an individual under the provisions of 14 Code of Federal Regulations Part 91 as personal flight. Visual meteorological conditions prevailed for the flight, which operated without a flight plan. The flight originated from Central Nebraska Regional Airport (KGRI) at 1345. While the student pilot was on downwind of his third traffic pattern, during his prelanding checks, the pilot noted that his selected right fuel tank was empty. The pilot then selected the left fuel tank, which indicated 3/8 of a tank of fuel remaining. Approximately four minutes later the airplane lost power and the pilot landed into a field on airport property. The student pilot further stated that immediately after the forced landing, he started the airplane on the ground where the forced landing occurred and taxied back to the ramp with the left tank still selected. A mechanic inspected the engine fuel injection system and found no blockage or contamination in the distribution manifold or the fuel injector nozzles. Lastly, the mechanic drained the remaining fuel from both fuel tanks: The right fuel tank had 1.5 quarts of fuel remaining. The left fuel tank had 19.75 gallons of fuel remaining. ## Aircraft - Registration: [N3573R](https://openairdocs.org/deregistered/N3573R-2018-10-27), registration cancelled 2018-10-27, S/N M-756, built 1965 (OpenAirDocs) - Reported make and model: BEECH A23 - Registry model: [Beech A23](https://openairdocs.org/model/beech-a23) (registry code 1151204) (OpenAirDocs) - Registry engine: [Continental IO-346 series](https://openairdocs.org/engine/continental-io-346-series) (registry code 17033, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-756 - Engines: CONT MOTOR IO-346 SERIES 165 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Departed: KMCK, McCook, NE - Destination: KGRI, Grand Isle, NE - Flight plan: VFR - Airport: KGRI, Central Nebraska Regional, runway 31, 6,608 × 100 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 47; injuries: none; student; airplane ratings: single-engine land; medical: class 3, unknown; last flight review December 18, 2012; seat: left; flight hours: 95 total, 18 in this make and model, 65 as pilot in command, 1 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 16 knots - Visibility: 10 statute miles - Lowest ceiling: none - Altimeter: 29.70 inHg - Observed at: KGRI, 1 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 20121218028339A](https://openairdocs.org/incident/20121218028339A), Dec 18, 2012: Beech A23, Grand Island, NE, Substantial damage. Pilot was conducting solo stop and go landings in right closed traffic at the Grand Island Municipal Airport. While on final approach for his third and final… ## Docket (2 files) The files NTSB released with the investigation on July 31, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85849. 2.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389576&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - NTSB Record of Conversation-Pilot (item 2, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393643&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation-Pilot-Redacted.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.