CEN22LA040

NTSB accident investigation · Beech 23 · Abilene, TX · November 15, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
November 15, 2021, 11:50 local (17:50 UTC)
Place
Abilene, TX
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N8701MBeech 23
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20211115019569A
Case key
104267

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

On this page

Probable cause

The flight instructor’s inadequate fuel management, which resulted in a loss of engine power due to fuel starvation. Contributing to the accident was the missing placard showing the usable fuel quantity.

Findings · 4

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.

Planning/preparation: fuel planningPersonnel issues › Task performance · PilotBeech 23: 3 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech 23: 3 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelBeech 23: 3 casesAll aircraft: 1,695 casesProbable cause
Placards and markingsAircraft › Aircraft handling/service · Not specifiedBeech 23: 1 caseAll aircraft: 11 cases

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 flight instructor completed about a 1-hour instructional flight with a student pilot, then was able to add only 4.19 gallons of fuel due to an issue with the airport’s fuel pump. The flight instructor then completed another 1-hour flight with a second student pilot. During this flight they used both fuel tanks, switching between tanks about every 30 minutes, and the flight instructor thought there would have been about 11 gallons remaining in the left tank and about 3 gallons in the right tank. They had completed one touch-and-go landing, then after takeoff, about 500 ft above ground level, the engine sustained a loss of power. The flight instructor took control of the airplane and requested that the student pilot complete the emergency checklist for a loss of engine power. They were unable to restart the engine and made an emergency landing to an area of mesquite trees. The airplane sustained substantial damage to the wings, fuselage, and empennage. The initial postaccident examination revealed that the wing fuel tanks were breached during the impact with trees and there was no sign or smell of residual fuel at the accident site. A detailed examination of the engine and fuel system did not reveal any residual fuel in the fuel system or engine components, and there were no anomalies found that would have precluded normal operation. The airplane manufacturer issued service instructions in 1974 that increased the amount of total unusable fuel from 1 gallon to 7.6 gallons (3.8 gallons per tank). The instructions had not been complied with since there were no updated placards to indicate 26 gallons of usable fuel for each tank. A postaccident fuel consumption estimation was completed based on the available evidence, which concluded that there could have been up to 7.79 gallons of usable fuel available. Since there was no recorded engine data, fuel quantity data, fuel at the accident site, or fuel remaining the airplane, the investigation was unable to determine the exact amount of usable fuel available, if any, when the loss of engine power occurred. It is likely that the flight instructor’s misunderstanding of the usable fuel quantity, and his inadequate management of the available fuel, resulted in fuel starvation and a loss of engine power.

Factual narrative

On November 15, 2021, about 1150 central standard time, a Beech 23 airplane, N8701M, was substantially damaged when it was involved in an accident near Abilene Regional Airport (ABI), Abilene, Texas. The flight instructor received serious injuries and the student pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that on the morning of the accident, 4.19 gallons of fuel were added to the right fuel tank; no additional fuel was added due to an issue with the self-service fuel pump. After fueling, the instructor estimated that the airplane contained about 15 gallons in each the left and right tanks. The first instructional flight was 1 hour, and the airplane consumed an average of 8 gallons per hour in cruise flight. He estimated that after the first flight there would have been about 15 gallons remaining in the left tank and 7 gallons in the right tank. The second instructional flight was about 1.1 hours, during which they completed maneuvers in the local area then returned to ABI for practice landings. During this flight they used both fuel tanks equally, switching between tanks about every 30 minutes, and there would have been about 11 gallons remaining in the left tank and about 3 gallons in the right tank. They had completed one touch-and-go landing at ABI, then after takeoff, about 500 ft above ground level (agl), the engine sustained a loss of power. The flight instructor took control of the airplane and requested that the student pilot complete the emergency checklist for a loss of engine power. They were unable to restart the engine and made an emergency landing to an area of mesquite trees. The student pilot stated that, after the initial loss of engine power, he followed the checklist and switched the fuel selector from the left to the right fuel tank. He stated the engine started but sputtered like it was not getting fuel. The airplane owner stated that he had leased the airplane to two pilots who intended to use it for their flight instruction business. He estimated that on the morning of the accident there would have been about 32 gallons of fuel in the airplane. The responding Federal Aviation Administration Inspector reported that the fuel tanks were breached and there was no sign or smell of residual fuel at the accident site. The fuel line from the fuel pump to the carburetor was void of fuel. The carburetor bowl was intact, but the position of the wreckage prevented an examination of the contents of the bowl at the accident site. The airplane sustained substantial damage to the wings, fuselage, and empennage. Postaccident examination of the airplane revealed that the fuel selector handle was positioned to OFF, and when actuated, it moved through LEFT, RIGHT, and OFF positions without issue. Air was blown through the fuel selector in the LEFT and RIGHT positions with no obstructions noted. The fuel strainer was intact andattached to the airplane, and it did not contain any fuel or contaminants. The engine-driven fuel pump was intact and attached to the engine. The fuel pump actuated with no anomalies noted. The carburetor was found partially fractured near the butterfly valve area. There was no fuel in the carburetor bowl and no anomalies noted with the unit. The fuel tank filler ports were not placarded with any information. The fuel selector valve displayed placards that indicated 29 gallons of (usable) fuel for each tank. In 1974, Beechcraft Service Instructions No. 0624-281, Fuel System – Replacarding to indicate minimum fuel for takeoff and increase amount of unusable fuel, was issued for the accident airplane. The pilot’s operating handbook revealed that the total unusable fuel increased from 1 gallon to 7.6 gallons (3.8 gallons per tank). The instructions had not been complied with since there were no updated placards to indicate 26 gallons of usable fuel for each tank. A fuel consumption estimation was completed based on the available evidence, which used only information recalled by the owner and pilots and could not be validated with any recorded data or other evidence. The estimation concluded that there could have been up to 7.79 gallons of usable fuel available. The flight instructor later stated that he thought the airplane was equipped with a 59.8-gallon system and was not aware that the usable fuel was only 52.2 gallons. He added that accident was possibly a result of fuel exhaustion.

Aircraft

Registration
N8701M
Reported as
Beech 23
Category
Airplane
Serial number
M-485
Built
1963
Airframe hours
2,581
Engine
Lycoming O-320-D2B, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Lytle Aviaiton
Registered owner
Hartman Robert J
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 2, 2021
Airport
ABI · Abilene Rgnl, runway 17R/35L, 7,208 × 150 ft, asphalt
Equipment
Handheld GPS, ADS-B, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
25
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 8, 2021
Seat
Right
Restraint
Lap only
Flight hours
336 total · 3.3 in this make and model · 209.3 as pilot in command · 44.2 in the last 90 days · 10.3 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Injuries
Serious
Certificate
Student
Medical
Unknown
Seat
Left
Restraint
Lap only

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 37 °F
Altimeter
30.09 inHg
Observed at
KDYS, 9 nm away
METAR
KDYS 151756Z AUTO 21009KT 10SM CLR 27/03 A3009 RMK AO2 SLP168 T02670032 10267 20028 58011

Docket · 9

The files NTSB released with the investigation on November 8, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.4 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.

Other investigations on N8701M · 2

Matched to the same aircraft by N-number and date.