# NTSB CEN19FA210: Beech A36, N1809S, Chebanse, IL, July 5, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Field · Final report - Date: July 5, 2019, 13:41 local (18:41 UTC) - Place: Chebanse, IL - Coordinates: 40.991943, -87.835556 - Nearby events: https://openairdocs.org/map.md?lat=40.9919&lon=-87.8356&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Central Region - Parties: FAA Flight Standards, Continental Aerospace Technologies, Textron Aviation - NTSB case key (mKey): 99774 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA210 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99774/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99774 - Page: https://openairdocs.org/ntsb/CEN19FA210 ## Probable cause A total loss of engine power due to fuel starvation. ## 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 A36, 22 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151604), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [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 A36, 17 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151604), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [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 A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot reported that, during a cross-country flight, while in cruise altitude at 3,000 ft mean sea level, the engine lost power. He subsequently performed a forced landing to a muddy wheat field. Examination at the site revealed that the left and right main fuel tanks were intact; the left tank was empty and the right tank contained about 25 gallons. The wing tip tanks were breached during the accident, but burns in the field were indicative of fuel being in the wing tip tanks at the time they were breached. The fuel selector was found in the left tank position. Further examination revealed that the fuel line from the fuel selector to the engine-driven fuel pump contained no fuel. A test run of the engine revealed no anomalies. Given the absence of fuel in the left tank, the position of the fuel selector at the accident site, and the engine's nominal performance during a postaccident test run, it is likely that the engine consumed all of the available fuel in the left fuel tank, which resulted in fuel starvation and a subsequent total loss of engine power. ## Factual narrative The pilot stated that the airplane's main and wing tip fuel tanks were filled to capacity before departing 1H2. The airplane was not fueled at MQY. He stated that he normally used a cruise power setting of 2,300 rpm and 23" manifold pressure. The airplane was equipped with two main tanks that held a total of 80 gallons, of which 74 gallons were useable. The two wing tip fuel tanks had a total capacity of 30 gallons, of which all 30 gallons were useable. The flight manual supplement noted that fuel was transferred from each wing tip tank to the respective main tank by an electric fuel transfer pump. Narrative airport information place holder On July 5, 2019, at 1341 central daylight time, a Beech A36 airplane, N1809S, was substantially damaged when it was involved in an accident near Chebanse, Illinois. The pilot sustained serious injuries, one passenger was fatally injured, and one passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Data from the ForeFlight application revealed that the airplane departed Effingham Memorial Airport (1H2), Effingham, Illinois, at 0901 and arrived at Smyrna Airport (MQY), Smyrna, Tennessee, at 1034. After picking up a passenger, the pilot departed MQY at 1134 for Bolingbrook's Clow International Airport (1C5), Bolingbrook, Illinois; climbing to a cruise altitude of 3,000 ft msl. The pilot reported that the takeoff and initial portion of the accident flight were routine, and the engine was running "fine." While in cruise, he heard a "big boom," and the engine lost power. He noted that the engine seemed to be running but was not producing any power; the engine indications were normal. The pilot performed a forced landing to a wheat field. Upon touchdown, the wheels "stuck" due to the muddy conditions and the airplane came to an abrupt stop. The pilot recalled checking the fuel quantity gauges shortly before the loss of power; he stated that one main tank was over 1/2 full and the other was about 3/4 full. He had not activated the wing tip fuel tank transfer pumps because there was still over 1/2 fuel remaining in the main tanks. Winds aloft along the route of flight were from the west-southwest about 8 knots. The pilot satisfactorily completed the flight instructor practical test on September 2, 2018, which met the requirement for a flight review in accordance with 14 CFR Part 61.56 (d) (2). The airplane came to rest in a muddy wheat field. The fuselage and both wings were damaged during the forced landing. Both wing tip fuel tanks were compromised. The wheat field was scorched in an area behind the left wing tip and below and behind the right wing tip. Both main wing fuel tanks appeared intact and both fuel caps were securely installed. At the time of the examination, the left main fuel tank was empty, and the right main fuel tank contained about 25 gallons of fuel. The fuel selector was positioned to the left main fuel tank. No fuel wasobserved in the fuel line from the fuel selector to the engine-driven fuel pump. Minimal fuel was observed in the fuel line from the fuel manifold to the mixture control. No residual fuel was expelled from the engine-driven fuel pump when it was operated manually. The auxiliary fuel pump switch was in the off position. The switch for the left wing tip fuel tank transfer pump was off, and the switch for the right wing tip tank transfer pump was on. An airframe examination did not reveal any anomalies consistent with a preimpact failure or malfunction. An engine test run was conducted, during which the engine performed normally and responded to all throttle inputs without hesitation. During the test run, fuel leaks were observed at the throttle body/mixture control and the engine-driven fuel pump. The o-rings in both components were removed and found to be hardened, worn, and brittle. The o-rings were replaced, and the components performed normally during the test run. The engine test run revealed no anomalies consistent with an inability to produce rated power. The airplane was equipped with a Shadin Microflo-L fuel management system. The operating manual noted that the Microflo-L is a fuel flow measuring system and not a quantity-sensing system. Positive determination of the usable fuel on-board and accurate entry of that information into the unit is required; however, the pilot reported that he did not recall initializing the system before either flight on the day of the accident. The airplane was also equipped with an Insight G1 graphic engine monitor. However, the unit did not have data logging capability. ## Aircraft - Registration: [N1809S](https://openairdocs.org/deregistered/N1809S-2022-11-05), registration cancelled 2022-11-05, S/N E-1875, built 1981 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-1875 - Year built: 1981 - Airframe hours: 4135 - Engines: Continental Motors IO-520-BB(17) 285 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 2, 2019, 5 hours before - Departed: MQY, Smyrna, TN - Destination: 1C5, Bolingbrook, IL - Airport: IKK, Greater Kankakee - Equipment: Auto-pilot, Electronic flight bag or handheld device, Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: serious; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, waiver time limited special; last flight review September 2, 2018; seat: left; restraint: 3-point; toxicology performed; flight hours: 2,823 total, 334 in this make and model, 2,635 as pilot in command, 62 in the last 90 days, 24 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 72 °F - Altimeter: 30.01 inHg - Observed at: IKK, 5 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 20190705009229A](https://openairdocs.org/incident/20190705009229A), Jul 5, 2019: Beech A36, Chebanse, IL, Substantial damage, 1 fatal. On Friday 05 July 2019, at or about 1315 CST, a Beech A36, N1809S, crashed in a wheat field 6 miles south of kankakee valley airport after suspected engine… ## Docket (25 files) The files NTSB released with the investigation on November 17, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99774. 126 MB in all. - Pilot statement (item 1, PDF, 3 pages, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9826221&FileExtension=pdf&FileName=Pilot%20Statements-Rel.pdf - Plot of airplane position data (item 2, PDF, 2 pages, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9110922&FileExtension=pdf&FileName=Plot%20of%20Airplane%20Position%20Data-Rel.pdf - Conversation summaries -- fixed base operators (mqy) (item 3, PDF, 2 pages, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9111271&FileExtension=pdf&FileName=Converation%20Summaries%20--%20Fixed%20Base%20Operators%20(MQY)-Rel.pdf - Airplane examination summary (item 4, PDF, 4 pages, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9123622&FileExtension=pdf&FileName=On-Scene%20Examination%20Summary%20--%20CEN19FA210-Rel.pdf - Engine examination summary (item 5, PDF, 3 pages, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9110650&FileExtension=pdf&FileName=Engine%20Examination%20Summary%20--%20CEN19FA210-Rel.pdf - Engine test run log sheet (item 6, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9110940&FileExtension=pdf&FileName=Engine%20Test%20Log-Rel.pdf - Accident report photos (item 7, PDF, 12 pages, 5.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9111599&FileExtension=pdf&FileName=Report%20Photos%20--%20CEN19FA210-Rel.pdf - Maintenance records -- airframe (item 8, PDF, 28 pages, 32.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9826808&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Airframe_redacted-Rel.pdf - Maintenance records -- engine (item 9, PDF, 17 pages, 20.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9826888&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Engine_redacted-Rel.pdf - Maintenance records -- propeller (item 10, PDF, 9 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9827261&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Propeller_redacted-Rel.pdf - Maintenance records -- airworthiness directives (item 11, PDF, 4 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9111808&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Airworthiness%20Directives_redacted-Rel.pdf - Maintenance records -- weight & balance (item 12, PDF, 1 page, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9827337&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Weight%20%26%20Balance_redacted-Rel.pdf - Airplane flight manual (excerpt) -- climb fuel/cruise power settings (item 13, PDF, 5 pages, 366 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9121341&FileExtension=pdf&FileName=Beech%20A36%20POH-AFM%20(Excerpt)%20--%20Climb%20Fuel_Cruise%20Power%20Settings-Rel.pdf - Airplane flight manual (excerpt) -- engine failure emergency procedure (item 14, PDF, 2 pages, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9110873&FileExtension=pdf&FileName=Beech%20A36%20POH-AFM%20(Excerpt)%20--%20Engine%20Failure%20Emerg%20Proc-Rel.pdf - Airplane flight manual (excerpt) -- fuel system description (item 15, PDF, 6 pages, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9123297&FileExtension=pdf&FileName=Beech%20A36%20POH-AFM%20(Excerpt)%20--%20Fuel%20System%20Description-Rel.pdf - Airplane flight manual supplement -- wing tip fuel tanks (item 16, PDF, 3 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9826185&FileExtension=pdf&FileName=Beech%20A36%20AFM%20Supplement%20--%20Wing%20Tip%20Fuel%20Tanks_redacted-Rel.pdf - Pilot's logbook (item 17, PDF, 36 pages, 42.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9828676&FileExtension=pdf&FileName=Pilot%20Logbook%20--%20Raymond%20Jakubiak_redacted-Rel.pdf - Weather observations -- kankakee airport (item 18, PDF, 3 pages, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9110389&FileExtension=pdf&FileName=Weather%20Observations%20--%20Greater%20Kankakee%20Airport-Rel.pdf - Winds aloft data (item 19, PDF, 1 page, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9112772&FileExtension=pdf&FileName=Winds%20Aloft%20Data-Rel.pdf - Statement of party representatives to NTSB investigation (item 20, PDF, 2 pages, 9.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9111170&FileExtension=pdf&FileName=Party%20Forms%20--%20CEN19FA210_redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 21, PDF, 1 page, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9856686&FileExtension=pdf&FileName=Release%20of%20Wreckage%20--%20CEN19FA210-acknowledged_redacted-Rel.pdf - Personal electronic device - specialist's factual report (item 22, PDF, 7 pages, 826 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9195477&FileExtension=pdf&FileName=Personal%20Electronic%20Device%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to personal electronic device - specialist's factual report (item 23, CSV, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9195991&FileExtension=csv&FileName=Attachment%201%20to%20Personal%20Electronic%20Device%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Attachment 2 to personal electronic device - specialist's factual report (item 24, CSV, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9195724&FileExtension=csv&FileName=Attachment%202%20to%20Personal%20Electronic%20Device%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Digital fuel monitor - specialist's factual report (item 25, PDF, 5 pages, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9821624&FileExtension=pdf&FileName=Digital%20Fuel%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.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.