# NTSB CEN19LA194: Beech A23, N3598R, Fort Smith, AR, July 1, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 1, 2019, 11:55 local (16:55 UTC) - Place: Fort Smith, AR - Coordinates: 35.334445, -94.265556 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.3344&lon=-94.2656&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA Flight Standards - NTSB case key (mKey): 99747 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA194 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99747/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99747 - Page: https://openairdocs.org/ntsb/CEN19LA194 ## Probable cause A total loss of engine power due to fuel starvation as a result of the flight instructor's fuel mismanagement. ## 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 · Instructor/check pilot (probable cause); cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151204), [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 management (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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: 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) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A23, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151204), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N3598R-2021-07-03), registration cancelled 2021-07-03, S/N M-779, 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-779 - Year built: 1965 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 28; injuries: none; 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 - Student pilot; age 18; injuries: none; 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 ## 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 20190701008829A](https://openairdocs.org/incident/20190701008829A), Jul 1, 2019: Beech A23, Fort Smith, AR, Substantial damage. N3598R departed Fort Smith Regional Airport (kfsm) at 10:30 am. On 1 July, 2019 with pilot and student onboard. After flying approximately 45 minutes at kfsm… ## Docket (8 files) The files NTSB released with the investigation on September 20, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99747. 5.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 940 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476126&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Flight Instructor Statement (to NTSB) (item 2, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476127&FileExtension=.PDF&FileName=Flight%20Instructor%20Statement%20(to%20NTSB)-Master.PDF - Flight Instructor Statement (to FAA) (item 3, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476128&FileExtension=.PDF&FileName=Flight%20Instructor%20Statement%20(to%20FAA)-Master.PDF - Student Pilot Statement (item 4, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476129&FileExtension=.PDF&FileName=Student%20Pilot%20Statement-Master.PDF - Operator Statement (item 5, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476130&FileExtension=.PDF&FileName=Operator%20Statement-Master.PDF - FAA Inspector Statement (item 6, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476131&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Recovery Personnel Statement (item 7, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476132&FileExtension=.PDF&FileName=Recovery%20Personnel%20Statement-Master.PDF - Airplane Maintenance Records (Excerpts) (item 8, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476133&FileExtension=.PDF&FileName=Airplane%20Maintenance%20Records%20(Excerpts)-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.