# NTSB CEN19TA073: Beech A36, N36PS, Fort Worth, TX, January 27, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Final report - Date: January 27, 2019, 16:34 local (22:34 UTC) - Place: Fort Worth, TX - Coordinates: 32.755832, -97.297775 - Nearby events: https://openairdocs.org/map.md?lat=32.7558&lon=-97.2978&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report August 10, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 98908 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19TA073 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98908/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98908 - Page: https://openairdocs.org/ntsb/CEN19TA073 ## Probable cause The pilot's improper fuel management, which resulted in fuel starvation and a loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 8 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1151604), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=1151604), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Beech A36, 15 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151604), [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 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) - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Beech A36, 12 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=1151604), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## 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](https://openairdocs.org/deregistered/N36PS-2020-02-28), registration cancelled 2020-02-28, S/N E-1012, built 1977 (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-1012 - Year built: 1977 - Airframe hours: 3300 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: minor; 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 ## 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 20190127023869A](https://openairdocs.org/incident/20190127023869A), Jan 27, 2019: Beech A36, Fort Worth, TX, Substantial damage. Aircraft was in cruise flight when it lost power and landed gear down in a field near a river bank. The aircraft suffered substantial damage when the right… ## Docket (4 files) The files NTSB released with the investigation on February 28, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98908. 3.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470678&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Telephone Conversation (item 2, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470679&FileExtension=.PDF&FileName=Record%20of%20Telephone%20Conversation-Master.PDF - Certification of Party Representative to NTSB Investigation (item 3, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470680&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative%20to%20NTSB%20Investigation-Master.PDF - Report Photos (item 4, .PDF, 3 photos, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470681&FileExtension=.PDF&FileName=Report%20Photos-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.