CEN19LA194

NTSB accident investigation · Beech A23 · Fort Smith, AR · July 1, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 1, 2019, 11:55 local (16:55 UTC)
Place
Fort Smith, AR
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3598RBeech A23
Defining event
Enroute: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA Flight Standards
FAA report
20190701008829A
Case key
99747

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A total loss of engine power due to fuel starvation as a result of the flight instructor's fuel mismanagement.

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotBeech A23: 3 casesAll aircraft: 1,391 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech A23: 3 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 flight instructor reported that the engine lost all power about 1 minute after he switched fuel tanks while returning to the airport after a local training flight. His efforts to restore engine power were unsuccessful and he performed a forced landing to a road. The airplane touched down hard and subsequently came to rest in a ditch adjacent to the road. Recovery personnel drained about 15 gallons of fuel from the left wing fuel tank and about 1/4 gallon from the right wing fuel tank. The fuel tanks appeared to be intact and no fuel leakage was observed. A postaccident engine test run was conducted with no anomalies. Based on the minimal amount of fuel recovered from the right tank, it is likely that the flight instructor exhausted the fuel in the right tank and did not switch to the left fuel tank in sufficient time to restore engine power, which resulted in fuel starvation and the total loss of engine power.

Factual narrative

On July 1, 2019, about 1155 central daylight time, a Beech A23 airplane, N3598R, experienced a hard landing on a road following a loss of engine power about 5 miles east of the Ft. Smith Regional Airport (FSM), Ft. Smith, Arkansas. The flight instructor and student pilot were not injured. The airplane sustained substantial damage. The airplane was registered to BAP Group LLC and operated by Southern Eagle Flight School as a Title 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed at the time of the accident, and the flight was not operated on a flight plan. The local flight originated from FSM about 1030. The flight instructor reported that the purpose of the flight was to evaluate the skills and proficiency of a prospective student. After takeoff, the student pilot completed some work in the airport traffic pattern and then they proceeded to the local practice area. While returning to the airport, the instructor switched fuel tanks and about one minute later the engine lost power. He took control of the airplane and set up for a forced landing to a road. The airplane touched down hard, slid off the road and into an adjacent ditch. The nose and right main landing gears collapsed, and the engine mount and firewall were damaged. The student pilot stated that after takeoff they proceeded to the practice area and completed some private pilot maneuvers. While returning to the airport, the flight instructor changed fuel tanks since they had been drawing from one tank for the entire flight. She did not recall which tank was selected. About 5 minutes later, the engine started to "sputter" and lost power. The instructor took control of the airplane. She noted that the instructor verified the fuel selector position but did not recall him resetting the fuel selector back to the original tank at that time. Airplane recovery personnel reported about 15 gallons of fuel was drained from the left-wing fuel tank and about 1/4 gallon was drained from the right fuel tank. The fuel tanks appeared to be intact and no fuel leakage was observed. An engine run was conducted under oversight of a Federal Aviation Administration inspector. The engine started and ran normally on both the left and the right fuel selector positions from an external fuel supply. The electric fuel boost pump was used during the engine start; however, after starting the boost pump was turned off and the engine run was conducted using only the engine driven fuel pump. A magneto check revealed no anomalies. A representative of the flight school reported that the airplane had been flown about 1-1/2 hours since it was topped off. The airplane was not fueled before the accident flight. He stated that the fuel level in the right tank was slightly below one-half full. He did not check the fuel level in the left tank; however, he observed the flight instructor conduct a complete preflight inspection. He noted that the airplane fuel selectorincorporated left, right, and off positions. Utilizing fuel from both tanks simultaneously was not an option; there was no both setting on the selector. The flight instructor stated that he visually checked the fuel levels before the flight and estimated about 35 gallons were on-board, which amounted to about 3-1/2 hours flight time. He added that the fuel gauges indicated full and the fuel samples taken during the preflight inspection were unremarkable.

Aircraft

Registration
N3598R
Reported as
Beech A23
Category
Airplane
Serial number
M-779
Built
1965
Engine
Continental IO-346-A, 165 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Southern Eagle Flight School
Registered owner
BAP Group LLC
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · April 4, 2019 · 16 hours before
Departed
FSM · Fort Smith, AR
Destination
FSM · Fort Smith, AR
Airport
FSM · Fort Smith Regional
Equipment
Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
28
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 20, 2019
Seat
Right
Restraint
3-point
Flight hours
367 total · 6 in this make and model · 182 as pilot in command · 100 in the last 90 days · 56 in the last 30 days · 0 in the last 24 hours
Role
Student pilot
Age
18
Injuries
None
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
16 total · 16 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 73 °F
Altimeter
30.04 inHg
Observed at
FSM, 5 nm away

Docket · 8

The files NTSB released with the investigation on September 20, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.5 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.