CEN21LA219

NTSB accident investigation · Beech B24R · New Lenox, IL · May 13, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
May 13, 2021, 11:17 local (16:17 UTC)
Place
New Lenox, IL
Injuries
3 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9199SBeech B24R
Defining event
Initial climb: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Lycoming Engines, FAA -- Flight Standards
FAA report
20210513008909A
Case key
103082

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 total loss of engine power due to fuel contamination as a result of the pilot’s improper fueling of the airplane.

Findings · 3

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionBeech B24R: 3 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Incorrect service/maintenanceBeech B24R: 3 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech B24R: 4 casesAll aircraft: 1,391 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 fueled the airplane using containers kept in the flying club hangar. Unknown to the pilot, one of the containers contained water, which he added to the left fuel tank. He noted that no water was observed when the fuel tanks were sumped as part of the preflight inspection; although, there was likely insufficient time for the water to settle out. The engine run-up, takeoff, and initial climb were conducted with the right fuel tank selected and were routine. However, when the pilot changed to the left fuel tank during the climb, the engine lost power. He executed a forced landing to an interstate highway. About 2-1/2 gallons of water were drained from the left fuel tank following the accident. No water was detected in the right fuel tank. No anomalies with respect to the engine assembly or the airframe fuel system were observed. An individual associated with the flying club reported that he was cleaning an airplane in the hangar the day before the accident. He had used a fuel container to get water and marked it, “water for cleaning.” At the end of the day, he left the container next to the airplane with the intention of continuing the next day. There were 2 to 3 gallons of water in the container at the time.

Factual narrative

On May 13, 2021, at 1117 central daylight time, a Beech B24R airplane, N9199S, was substantially damaged when it was involved in an accident near New Lenox, Illinois. The pilot and 2 passengers were seriously injured, and 1 passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported the airplane was fueled from four identical fuel containers kept in the flying club hangar. One container was already full. He took the other three containers to the fuel pump, filled them with 100 low-lead aviation fuel, and returned to the airplane. He added about 10 gallons of fuel to each wing fuel tank from the four containers. Shortly afterward, during the preflight inspection, he sumped the fuel tanks and did not observe any contamination. The engine started without hesitation, and the before takeoff run-up, takeoff, and initial climb out were normal. The right fuel tank was selected for the takeoff and initial climb; however, he then switched the left fuel tank. Shortly after changing tanks, the engine lost power. His efforts to restore engine power were not successful, and he executed a forced landing to an interstate highway. The airplane impacted a concrete barrier wall during the landing. A postaccident examination recovered approximately 2-1/2 gallons of water from the left fuel tank. No water was detected in the right fuel tank. No anomalies with respect to the engine assembly or the airframe fuel system were observed. An individual associated with the flying club reported that he was cleaning an airplane in the hangar the day before the accident flight. He had used a fuel container to get water and marked it, “water for cleaning”. At the end of the day, he left the container next to the airplane with the intention of continuing the next day. There were 2 to 3 gallons of water in the container at the time.

Aircraft

Registration
N9199S
Reported as
Beech B24R
Category
Airplane
Serial number
MC-371
Built
1975
Airframe hours
3,843.8
Engine
Lycoming IO360-A1B6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 2, 2020 · 85.7 hours before
Departed
LOT · Romeoville, IL
Destination
EYE · Indianapolis, IN
Airport
LOT · Lewis University, runway 2, 6,500 × 100 ft, concrete
Equipment
Stall warning system, ADS-B

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
40
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
January 13, 2021
Seat
Left
Restraint
3-point
Flight hours
128.7 total · 30.5 in this make and model · 68.6 as pilot in command · 11.5 in the last 90 days · 1 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 36 °F
Altimeter
30.42 inHg
Observed at
LOT, 5.87 nm away

Docket · 14

The files NTSB released with the investigation on July 27, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 520 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.