# NTSB CEN21LA219: Beech B24R, N9199S, New Lenox, IL, May 13, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: May 13, 2021, 11:17 local (16:17 UTC) - Place: New Lenox, IL - Coordinates: 41.5524, -87.9806 - Nearby events: https://openairdocs.org/map.md?lat=41.5524&lon=-87.9806&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: Serious injuries - Injuries: 3 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, FAA -- Flight Standards - NTSB case key (mKey): 103082 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA219 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103082/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103082 - Page: https://openairdocs.org/ntsb/CEN21LA219 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Beech B24R, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151253), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Beech B24R, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151253), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech B24R, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151253), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Beech B24R, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=1151253), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech B24R, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151253), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech B24R, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151253), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech B24R, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151253), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N9199S-2023-03-04), registration cancelled 2023-03-04, S/N MC-371, built 1975 (OpenAirDocs) - Reported make and model: BEECH B24R - Registry model: [Beech B24R](https://openairdocs.org/model/beech-b24r) (registry code 1151253) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MC-371 - Year built: 1975 - Airframe hours: 3843.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: serious; 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 ## 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 20210513008909A](https://openairdocs.org/incident/20210513008909A), May 13, 2021: Beech B24R, New Lenox, IL, Substantial damage. When: 05/13/2021 16:18Z Where: New Lenox, IL, interstate I-355 southbound center median near the route 6 off ramp. A private pilot was operating a Beechcraft… ## Docket (14 files) The files NTSB released with the investigation on July 27, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103082. 520 MB in all. - Pilot statement (item 1, PDF, 2 pages, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12385116&FileExtension=pdf&FileName=Pilot%20Stmt%20--%20Jason%20Bufton_redacted-Rel.pdf - Accident photos (item 2, PDF, 10 pages, 7.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12392267&FileExtension=pdf&FileName=Accident%20Photos%20--%20CEN21LA219-Rel.pdf - Airplane examination summary (item 3, PDF, 3 pages, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12380349&FileExtension=pdf&FileName=Examination%20Summary%20--%20CEN21LA219-Rel.pdf - Owner / flying club statement (item 4, PDF, 1 page, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12385356&FileExtension=pdf&FileName=ROC%20--%20Duane%20Hummell%20--%2027May2021-Rel.pdf - FAA inspector statement (item 5, PDF, 1 page, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12384678&FileExtension=pdf&FileName=ROC%20--%20FAA_Paul%20Adams%20--%2026May2021-Rel.pdf - Pilot logbook -- excerpt (item 6, PDF, 3 pages, 9.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12379540&FileExtension=pdf&FileName=Pilot%20Logbook%20(Excerpt)%20--%20Jason%20Bufton_redacted-Rel.pdf - Maintenance records -- airframe (item 7, PDF, 28 pages, 415 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12388563&FileExtension=pdf&FileName=Airframe%20Log%20(Excerpt)_redacted-Rel.pdf - Maintenance records -- engine (item 8, PDF, 40 pages, 82.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12387463&FileExtension=pdf&FileName=Maintenance%20Records%20--%20Engine_redacted-Rel.pdf - Maintenance records -- propeller (item 9, PDF, 9 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12386346&FileExtension=pdf&FileName=Propeller%20Log_redacted-Rel.pdf - Maintenance records -- weight & balance (item 10, PDF, 1 page, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12385941&FileExtension=pdf&FileName=Weight%20%26%20Balance%20(Apr2018)_redacted-Rel.pdf - Airplane log sheet (item 11, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12386356&FileExtension=pdf&FileName=Flight%20Log%20Sheet-Rel.pdf - Maintenance records -- airplane status sheet (item 12, PDF, 1 page, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12386043&FileExtension=pdf&FileName=Aircraft%20Status%20Sheet_redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 1 page, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12380407&FileExtension=pdf&FileName=Party%20Stmt%20--%20CEN21LA219%20(Lycoming)_redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 14, PDF, 1 page, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12388411&FileExtension=pdf&FileName=Release%20of%20Wreckage%20--%20CEN21LA219_redacted-Rel.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.