CEN19TA073

NTSB accident investigation · Beech A36 · Fort Worth, TX · January 27, 2019

Accident · Serious injuriesFinal report
Date
January 27, 2019, 16:34 local (22:34 UTC)
Place
Fort Worth, TX
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N36PSBeech A36
Defining event
Approach-VFR pattern final: Fuel related
Weather
Visual (VMC) · Day
Status
Completed · report August 10, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards District Office
FAA report
20190127023869A
Case key
98908

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

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Probable cause

The pilot's improper fuel management, which resulted in fuel starvation and a loss of engine power.

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.

Action: lack of actionPersonnel issues › Action/decision · PilotBeech A36: 8 casesAll aircraft: 792 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech A36: 22 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 pilot stated that before departure, both fuel tanks were 3/4 full and that he maintained fuel balance by switching between the left and right tanks "several times" during the flight. As he approached his destination, he requested and received vectors for a practice instrument approach to a nearby airport but then requested termination of the approach and said he would proceed to his original destination. Shortly after the airplane climbed to 1,500 ft (900 ft above ground level), the engine lost power. The pilot switched the fuel selector "to the other tank" and attempted to restart the engine to no avail. He stated that he did not turn on the electric boost pump (as required in the emergency checklist) and that the airplane was too low to the ground for him to reference the emergency checklist. He lowered the landing gear but did not lower the flaps for landing. The airplane touched down on soft earth, and the nose gear collapsed, resulting in substantial damage to the nose. An unknown quantity of fuel was drained from the left tank, and the right tank was empty. The fuel that was sumped from the airplane's left tank appeared to be clear, bright, and free of contaminants. The fuel selector was positioned on the left tank. No mechanical malfunctions or failures were noted with the engine or fuel system that would have precluded normal operations. It is likely the engine lost power due to fuel starvation and the pilot failed to switch fuel tanks before exhausting the fuel in the right tank.

Factual narrative

***This report was modified on July 20, 2020. Please see the docket for this accident to view the original report.*** On January 27, 2019, at 1634 central standard time a Beech A36, N36PS, lost engine power during a practice instrument approach to Fort Worth Meacham International Airport (FTW), Fort Worth, Texas. The airline transport certificated pilot made an off-airport forced landing in a field 5 miles southeast of FTW. The pilot sustained minor injuries, and the passenger was seriously injured. The airplane sustained substantial damage to the forward portion of the fuselage. The airplane was registered to and operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions were reported at the airport about the time of the accident, and no flight plan had been filed for the flight that originated from Angel Fire, New Mexico (AXX), at 1300 and was en route to Arlington Municipal Airport (GKY), Arlington, Texas. The pilot told the inspector that before departing AXX, both fuel tanks were 3/4 full. He also indicated this in his accident report. He said he maintained fuel balance by switching between the left and right tanks "several times" during the flight. As he approached the DFW (Dallas-Fort Worth) TCA (Terminal Control Area), he requested and received vectors for a practice ILS (instrument landing system) [runway] 34 approach to FTW. Following slower traffic, he requested termination of the approach and said he would continue on to GKY. Shortly after climbing to 1,500 feet, the engine lost power. The pilot switched the fuel selector "to the other tank" and attempted to restart the engine to no avail. He said he failed to turn on the electric boost pump (as required in the emergency checklist) and that, because of the airplane's low altitude, he did not have time to refer to the emergency checklist. He lowered the landing gear but elected not to lower the flaps for landing. The airplane touched down on soft earth, the nose gear collapsed, and the airplane nosed down. A Federal Aviation Administration (FAA) inspector inspected the wreckage and sumped clear, bright fuel from the airplane's left fuel tank that appeared to be free of contaminants. The fuel gauges indicated slightly more than 1/4 full in the left fuel tank but the right tank was empty. Visual inspection of the tanks revealed a small, unknown fuel quantity in the left tank and the right fuel tank was empty. The fuel selector was positioned on the left tank. No mechanical anomalies were noted with the engine or fuel system that would have precluded normal operations.

Aircraft

Registration
N36PS
Reported as
Beech A36
Category
Airplane
Serial number
E-1012
Built
1977
Airframe hours
3,300
Engine
Continental, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 15, 2018
Departed
AXX · Angel Fire, NM
Destination
GKY · Arlington, TX
Airport
FTW · Fort Worth Meacham Internation, runway 34, 7,502 × 150 ft, concrete

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
Minor
Certificates
Flight instructor, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Powered-lift, Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 5, 2018
Seat
Left
Restraint
3-point
Flight hours
5,290 total · 320 in this make and model · 4,005 as pilot in command · 50 in the last 90 days · 23 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 25 °F
Altimeter
30.02 inHg
Observed at
FTW, 5 nm away

Docket · 4

The files NTSB released with the investigation on February 28, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.2 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.