# NTSB CEN17LA348: Beech N35, N9368Y, South Bend, IN, September 12, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 12, 2017, 13:35 local (18:35 UTC) - Place: South Bend, IN - Coordinates: 41.708332, -86.317222 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.7083&lon=-86.3172&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 15, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 95995 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA348 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95995/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95995 - Page: https://openairdocs.org/ntsb/CEN17LA348 ## Probable cause The improperly seated fuel cap, which resulted in an in-flight fuel leak and subsequent total loss of engine power due to fuel starvation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [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 N35, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151528), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech N35, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151528), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=1151528), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Misc hardware](https://openairdocs.org/ntsb-findings/01071400): Aircraft › Fluids/misc hardware · Incorrect use/operation; cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-findings/01071400/cases.md?model=1151528), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01071400/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech N35, 3 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151528), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech N35, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151528), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech N35, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151528), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech N35, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151528), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The commercial pilot reported that the airplane was nearing the destination at the conclusion of a long cross-country flight when the engine experienced a total loss of power. The pilot declared an emergency and conducted a forced landing to a highway. During the forced landing, the airplane struck an elevated island and a car and was substantially damaged. A postaccident examination of the airplane revealed blue-colored fuel stains streaking from the right wing fuel filler aft to the trailing edge of the right wing flap. The right fuel tank contained 1 cup of fuel and the left fuel tank had about 10 gallons of fuel. The fuel cap and seat were unremarkable. An examination of the engine and remaining systems revealed no anomalies. It is likely that the right fuel cap was not seated properly before takeoff, which resulted in the siphoning of the fuel during the flight, and a subsequent total loss of engine power due to fuel starvation. ## Factual narrative On September 12, 2017, about 1300 central daylight time, a Beech N35 airplane, N9368Y, was substantially damaged during a forced landing near South Bend International Airport (SBN), South Bend, Indiana. The commercial pilot and passenger were not injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no Federal Aviation Administration (FAA) flight plan had been filed for the flight. The flight departed Johnson County Executive Airport (OJC), Olathe, Kansas, about 0930, and was en route to SBN. According to the pilot, while on final approach for runway 9R, the engine "missed". The pilot attempted to increase engine power by advancing the engine throttle control forward. There was no response from the engine. During the forced landing the main landing gear clipped the elevated island between two oncoming lanes of traffic. The airplane bounced and struck a car before coming to rest in the grass adjacent to the road. The left wing was bent and buckled during the forced landing. Prior to the recovery of the airplane from the accident site, the FAA inspector, who responded to the accident, recovered about a cup of fuel from the right fuel tank. There was visible fuel in the left fuel tank. A postaccident examination of the airplane, following its recovery, revealed blue-colored fuel streaking from the right-wing fuel filler aft to the trailing edge of the right-wing flap. The right fuel tank was empty, and the left fuel tank had about 10 gallons of fuel. The fuel cap and seat were unremarkable. An examination of the engine and remaining systems revealed no anomalies that would have precluded normal operation. ## Aircraft - Registration: [N9368Y](https://openairdocs.org/deregistered/N9368Y-2019-05-06), registration cancelled 2019-05-06, S/N D-6569, built 1960 (OpenAirDocs) - Reported make and model: BEECH N35 (NO SERIES) - Registry model: [Beech N35](https://openairdocs.org/model/beech-n35) (registry code 1151528) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-6569 - Year built: 1960 - Airframe hours: 5275 - Engines: Continental IO-520-BB-10B 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 22, 2017 - Departed: KOJC, Olathe, KS - Destination: KSBN, South Bend, IN - Airport: SBN, South Bend International Airpo - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review August 18, 2016; seat: left; restraint: lap only; flight hours: 4,983 total, 460 in this make and model, 4,787 as pilot in command, 7 in the last 90 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 5° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 54 °F - Altimeter: 29.96 inHg - Observed at: kSBN, 1 nm away ## Docket (3 files) The files NTSB released with the investigation on April 16, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95995. 1.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 926 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461997&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (item 2, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461998&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40461999&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.