# NTSB CEN14LA393: Beech 35-C33A, N72CW, Pueblo, CO, July 27, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 27, 2014, 08:26 local (14:26 UTC) - Place: Pueblo, CO - Coordinates: 38.289165, -104.496665 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.2892&lon=-104.4967&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report January 14, 2015 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office, Textron Aviation, Continental Motors, Inc. - NTSB case key (mKey): 89753 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA393 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89753/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89753 - Page: https://openairdocs.org/ntsb/CEN14LA393 ## Probable cause A total loss of engine power due to fuel starvation, which resulted from the pilot’s improper fuel management and resulted in a forced landing on unsuitable terrain. ## 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-C33A, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151410), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 35-C33A, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151410), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 35-C33A, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1151410), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech 35-C33A, 2 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=1151410), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/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: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech 35-C33A, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151410), [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 35-C33A, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151410), [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 35-C33A, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151410), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, while on final approach with the engine idling, he advanced the mixture control to the "full rich" position and the propeller control to the "high rpm" position in case he had to perform a go-around. The engine immediately lost power, and the airplane started to lose altitude. The pilot turned the airplane to avoid a ravine ahead and subsequently made a forced landing on rough terrain. The engine was functionally tested in a test cell to full power, and no anomalies were noted. About 25 gallons of usable fuel were found in the right fuel tank. However, the fuel tank selector was found positioned to the left fuel tank, and only 1/2 gallon of fuel was found in the left tank; therefore, it is likely the engine was starved of available fuel. If the pilot had been monitoring the fuel in flight and switched the fuel tank selector to the right fuel tank, the engine likely would not have been starved of fuel. ## Factual narrative On July 27, 2014, at 0917 mountain daylight time, a Beech 35-C33A airplane, N72CW, impacted terrain short of runway 8L at Pueblo Memorial Airport (KPUB), Pueblo, Colorado. The pilot was not injured, but his passenger sustained serious injuries. The airplane was substantially damaged. The airplane was registered to and operated by Henke Petroleum Corporation of Shawnee, Oklahoma, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The flight originated from Shawnee Regional Airport (KSNL), Shawnee, Oklahoma, about 0725 central daylight time. According to the pilot's accident report, he was cleared to land on runway 8L at PUB. On final approach with the engine idling, he advanced the mixture control to FULL RICH and the propeller control to HIGH RPM in case he had to make a go-around. The engine immediately lost power and the airplane started losing altitude. The pilot saw a ravine ahead. He turned south to avoid the ravine and made a forced landing on rough terrain. On August13, 2014, the engine and airframe were examined at Beegles Aircraft Service in Greeley, Colorado. No airframe anomalies were found. Flight control continuity was established. The elevator trim indicator read 5 units UP. The left and right elevator trim actuator extensions were approximately 1 11/16 inches, equivalent to approximately 15° trim tab down (nose up). Both flap actuator extensions were measured and found to be about 1 9/16 inches, equivalent to approximately 0°, or flaps up. The landing gear switch was down and the landing gear actuator was extended. The Hobbs meter read 149.3 hours and the tachometer recorder read 976.29 hours. The fuel selector was found positioned on the left main fuel tank. A clear rudder tube was inserted into the left wing fuel pipe. Air was blown into the clear tube and fuel ejected from the fuel pipe. The fuel selector handle was rotated to the right main tank and the procedure was repeated. Fuel ejected from the fuel pipe. The left and right wing bladder fuel tanks were intact. The recovery crew stated that about 25 gallons of fuel was drained from the right wing, and about ½ gallon of fuel was drained from the left wing. The top spark plugs were removed and examined. When compared to the Champion Check-A-Plug chart, the color and wear patterns were consistent with a normal condition. The cylinders were examined using a lighted borescope. All cylinders were intact, undamaged, and appeared dry. They exhibited normal heat signatures with normal combustion deposits. The engine driven fuel pump drive coupling was examined and found intact. The pump was free to rotate by hand without restriction. The engine was shipped to Continental Motors in Mobile, Alabama, where, on October 30, 2014, it was functionally tested in a test stand. The engine was operated to full power and no anomalies were noted. There was,however, a small leak in the metering unit due to impact damage. The Continental Motors representative was asked to calculate to fuel consumed and the following is what he reported. The straight line distance from Shawnee, OK, to Pueblo, CO, is 464 nautical miles. At an average cruising speed of 160 knots, it would take about 2.9 hours to travel this distance. The IO-550 will burn about 16 gallons per hour (gph) in cruise flight. Thus, 46.4 gallons would be consumed in this time period. Subtracting 46.4 gallons from the 74 gallons useable would leave approximately 27.6 gallons. Subtracting 25 gallons that was recovered by the salvage crew from the right wing leaves 2.5 gallons, which is the amount estimated to have remained in the left tank. These calculations do not take into account winds aloft or the fuel consumed for takeoff (approximately 26 gph ), maneuvering after departure or upon arrival, and entering the traffic pattern. ## Aircraft - Registration: [N72CW](https://openairdocs.org/deregistered/N72CW-2018-05-31), registration cancelled 2018-05-31, S/N CE-69, built 1966 (OpenAirDocs) - Reported make and model: BEECH 35-C33A - Registry model: [Beech 35-C33A](https://openairdocs.org/model/beech-35-c33a) (registry code 1151410) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CE-69 - Year built: 1966 - Airframe hours: 2905 - Engines: Continental IO 550-B-AP 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Henke Petroleum Corp - Registered owner: Henke Petroleum Corp - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 8, 2013, 17 hours before - Departed: KSNL, Shawnee Regiona, OK - Destination: KPUB, Pueblo, CO - Airport: KPUB, Pueblo Memorial, runway 08L, 10,496 × 150 ft, asphalt - Equipment: Onboard weather, Electronic multifunction display, Electronic flight bag or handheld device, Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review December 10, 2013; seat: left; restraint: 3-point; flight hours: 1,254 total, 723 in this make and model, 1,171 as pilot in command, 9 in the last 90 days, 9 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 57 °F - Altimeter: 30.30 inHg - Observed at: KPUB ## 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 20140727013489A](https://openairdocs.org/incident/20140727013489A), Jul 27, 2014: Beech 35-C33A, Pueblo, CO, Substantial damage. Aircraft was on final approach for runway 8R at Pueblo, Colorado (Kpub). Engine started running rough. Pilot verified fuel tank selector, pushed mixture… ## Docket (7 files) The files NTSB released with the investigation on November 10, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89753. 1.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418804&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Email from Continental Motors - Engine Run Results (item 2, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418805&FileExtension=.PDF&FileName=Email%20from%20Continental%20Motors%20-%20Engine%20Run%20Results-Redacted.PDF - Email from Continental Motors - Fuel Consumption (item 3, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418806&FileExtension=.PDF&FileName=Email%20from%20Continental%20Motors%20-%20Fuel%20Consumption-Redacted.PDF - Photo 1 - Ground Scar (item 4, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418807&FileExtension=.PDF&FileName=Photo%201%20-%20Ground%20Scar-Master.PDF - Photo 2 - Left Front View (item 5, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418808&FileExtension=.PDF&FileName=Photo%202%20-%20Left%20Front%20View-Master.PDF - Photo 3 - Right Front View (item 6, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418809&FileExtension=.PDF&FileName=Photo%203%20-%20Right%20Front%20View-Master.PDF - Photo 4 - Engine (item 7, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418810&FileExtension=.PDF&FileName=Photo%204%20-%20Engine-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.