CEN23FA139

NTSB accident investigation · Beech 58P · Lubbock, TX · March 17, 2023

Accident · FatalClass 3 · FieldFinal report
Date
March 17, 2023, 11:40 local (16:40 UTC)
Place
Lubbock, TX
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N2061KBeech 58P
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
Textron Aviation, FAA - FSDO, Hartzell Propellar
FAA report
20230317001769A
Case key
106909

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 pilot’s failure to ensure a proper fuel selector position before takeoff, which resulted in a loss of left engine power due to fuel starvation. Contributing to the accident was the pilot’s failure to maintain airplane control after the loss of left engine power.

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.

Inspection: preflight inspectionPersonnel issues › Task performance · PilotBeech 58P: 1 caseAll aircraft: 551 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationBeech 58P: 1 caseAll aircraft: 176 casesProbable cause
Performance/control parameters: engine out controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech 58P: 1 caseAll aircraft: 35 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech 58P: 6 casesAll aircraft: 9,295 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 landed at the departure airport and dropped off passengers before the accident flight. The pilot then left the airplane while it was being fueled and returned after fueling was completed. The pilot walked around the airplane while talking on a cellular phone, which was not consistent with a proper preflight inspection of the airplane due to his diverted attention. After the engines were started, the airplane taxied to the departure runway. A witness stated that he did not see or hear an engine run-up before takeoff. The witness said the airplane’s takeoff was normal and later heard an audible change in engine sound after it had become airborne. Surveillance video recorded the airplane in a nose-down, left bank attitude before entering a left roll into an inverted attitude and impacting the ground. Postaccident examination of the airplane revealed that the left cockpit fuel selector was in the OFF position, which likely led to fuel starvation and a loss of left engine power. Additionally, the left engine propeller exhibited features of low/no power. The right propeller exhibited features consistent with higher power and a blade angle near takeoff/climb power. The initial left roll of the airplane likely resulted from the loss of left engine power. Examination of the engines revealed no preimpact mechanical malfunctions or failures. Flight control continuity of the airplane was confirmed and the continued left roll after the loss of left engine power indicated a loss of control by the pilot.

Factual narrative

Data download of the pilot’s personal electronics device showed that there was an incoming call at 11:28:14, before the accident. The phone call lasted 12 minutes and 34 seconds and ended at 11:40:48. The data also showed that the pilot’s phone was connected to an aviation headset via Bluetooth at 11:40:07. On March 17, 2023, about 1140 central daylight time, a Beech Baron 58P, N2061K, was destroyed when it was involved in an accident near Lubbock, Texas. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A fixed-base operator (FBO) surveillance video showed that the airplane arrived at the FBO ramp at Lubbock Executive Airpark (F82), Lubbock, Texas, about 1111. After the airplane came to a stop on the ramp, the engines were simultaneously shut down. The pilot exited the airplane, along with two adults and two children. The pilot left the ramp and later returned to the airplane about 1116 to remove baggage. A fuel truck then pulled up in front of the airplane to refuel the airplane, and the pilot again left the ramp. About 1123, fueling of the airplane was completed. The surveillance video showed the pilot walked out of the FBO building and onto the ramp toward the airplane about 1127 while holding a cell phone to his ear. He walked clockwise around the airplane while holding the cell phone, stopped behind the right wing root, then began walking in a counterclockwise direction. He stopped near the left engine while holding the cell phone and looking away from the airplane. Then he walked to the right front airplane door, which he entered about 1130. About 1131, he exited the airplane, stepped down behind the right wing, then reentered the airplane. About 1132, the left propeller began to rotate, stopped, then began to rotate again. About 1133, the right propeller began to rotate. About 1135, the airplane taxied on the ramp, and about 1136, the airplane held short of runway 35. About 1137, the airplane began its takeoff on runway 35. A witness saw the pilot of the accident airplane walk around the airplane while talking on a cell phone before the airplane’s engines started. The witness stated that he did not see or hear a run-up of the airplane’s engines before takeoff. The witness stated that the takeoff seemed like a normal takeoff. The witness stated that the airplane lifted off about 2,200 ft down the runway. Shortly after liftoff, and while the airplane was about 20-50 ft above the runway, he looked away to fill fuel from the fuel truck and then heard an audible change in engine sound. The witness then looked up at the airplane and saw it in a left bank. Another surveillance video recorded the airplane in a nose-down, left bank attitude before entering a left roll into an inverted attitude and impacting the ground. The airplane was destroyed by impact forces and a post-crash fire. An autopsy of the pilot was conducted by the Tarrant County Medical Examiner’sOffice, Fort Worth, Texas, on March 21, 2023. The autopsy report stated that the cause of death was blunt force injuries, and the manner of death was accident. The Federal Aviation Administration Civil Aerospace Medical Institute Forensic Toxicology Report for the pilot was negative for drugs of abuse. No pilot logbooks were recovered from the airplane. There was no record of the pilot’s flight experience or any record that the pilot met federal regulations for recency of experience. A twin-engine initial/recurrent training syllabus, dated March 14, 2023, and signed by a flight instructor, stated that the syllabus was completed using a Precision 6DOF MFD Advanced Aviation Training Device. There was no reference to federal regulations for a flight review or instrument proficiency check in this document. The accident site was about 0.5 nm west-northwest from the departure end of runway 35. The airplane wreckage was in a fallow and relatively flat cotton field, which was surrounded by similar fields. The major components of the airplane were accounted for at the accident site. Flight control continuity from the airplane control surfaces to the cockpit controls was confirmed. The landing gear was in the retracted position. Postaccident examination of the left and right engines revealed no preimpact mechanical anomalies that would have precluded normal engine operation. Impact forces damaged both propellers. The left propeller exhibited damage consistent with the propeller at or nearing the feathered position with low/no power. The right propeller exhibited damage consistent with rotation at higher power and at a blade angle consistent with takeoff/climb power. The left cockpit fuel selector handle sustained impact damage and was bent aft, pointing to a position between OFF and CROSSFEED. According to the aircraft manufacturer, this position is outside the normal operating range of the handle assembly. Disassembly of the left fuel selector valve assembly revealed the valve gear was in the OFF position. Continuity of the control cable was observed from the cockpit fuel selector assembly to the wing selector valve with no evidence of the cable having been pulled from impact forces. The right cockpit fuel selector handle sustained impact damage and was bent aft between the ON and CROSSFEED positions. Disassembly of the right fuel selector valve assembly revealed the valve gear was pulled beyond the OFF position by the control cable running from the assembly to the wing fuel selector valve.

Aircraft

Registration
N2061K
Reported as
Beech 58P
Category
Airplane
Serial number
TJ-161
Built
1978
Engines
Continental TSIO-520-WB, 310 hp, reciprocatingContinental TSIO-520-L, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Mile High Air Inc
Airworthiness certificate
Standard, Normal
Airport
F82 · Lubbock Executive Airpark, runway 35, 3,500 × 75 ft, asphalt
Equipment
Stall warning system, Auto-pilot, 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
26
Injuries
Fatal
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
920 total

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 10 knots, gusting 17
Visibility
10 statute miles
Lowest ceiling
7,500 ft broken
Temperature
37 °F, dew point 18 °F
Altimeter
30.26 inHg
Observed at
KLBB, 10 nm away
METAR
KLBB 171553Z 05010G17KT 10SM BKN075 03/M08 A3026 RMK AO2 SLP249 T00331083

Docket · 25

The files NTSB released with the investigation on August 7, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FBO surveillance video summaryItem 1 · PDF · 1 page · 67 KBFBO surveillance video - aircraft arrival on FBO ramp at 1111Item 2 · DAV · 37.5 MBFBO surveillance video - pilot and passengers exit aircraftItem 3 · DAV · 16.5 MBFBO surveillance video - pilot returns for baggage and fuel truck pulls up to aircraft at 1116Item 4 · DAV · 44.9 MBFBO surveillance video - fuelling of aircraft completed at 1123Item 5 · DAV · 52.2 MBFBO surveillance video - pilot walked out of the FBO building and onto the ramp at 1127Item 6 · DAV · 18.5 MBFBO surveillance video - pilot walking around aircraft at 1128Item 7 · DAV · 17.0 MBFBO surveillance video - pilot walking around aircraft at 1129Item 8 · DAV · 8.2 MBFBO surveillance video - pilot walking around aircraft at 1129 to engine start and taxiItem 9 · DAV · 145 MBFBO surveillance video - aircraft hold short and takeoff runway 35 at 1136-1137Item 10 · DAVFBO surveillance video - aircraft takeoff roll and lift-offItem 11 · DAV · 25.0 MBSurveillance video summary a�� jimmy mclearenItem 12 · PDF · 1 page · 63 KBSurveillance video of flight - provided by jimmy mclearenItem 13 · MOV · 23.1 MBAutomatic dependent surveillance broadcast plotItem 14 · KMZ · 338 KBAutomatic dependent surveillance broadcast dataItem 15 · XLSX · 8.2 MBRecord of examinationItem 16 · PDF · 2 pages · 71 KBEFIS - specialist's factual reportItem 17 · PDF · 5 pages · 790 KBPersonal electronic device - specialist's factual reportItem 18 · PDF · 3 pages · 223 KBTwin engine initial/recurrent training syllabus completionItem 19 · PDF · 4 pages · 59 KBStatement of party representatives to NTSB investigation - TextronItem 20 · PDF · 1 page · 535 KBStatement of party representatives to NTSB investigation - hartzell propellerItem 21 · PDF · 14 pages · 415 KBAircraft logbook excerptsItem 22 · PDF · 3 pages · 3.5 MBToxicological reportItem 23 · PDF · 1 page · 155 KBPhotosItem 24 · PDF · 7 pages · 1.9 MBRelease of aircraft wreckage, NTSB form 6120.15Item 25 · PDF · 1 page · 159 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.