# NTSB CEN23FA139: Beech 58P, N2061K, Lubbock, TX, March 17, 2023

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: March 17, 2023, 11:40 local (16:40 UTC)
- Place: Lubbock, TX
- Coordinates: 33.499833, -101.82021
- Nearby events: https://openairdocs.org/map.md?lat=33.4998&lon=-101.8202&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: Textron Aviation, FAA - FSDO, Hartzell Propellar
- NTSB case key (mKey): 106909
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23FA139
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106909/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106909
- Page: https://openairdocs.org/ntsb/CEN23FA139

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1152744), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md)
- [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=1152744), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md)
- [Performance/control parameters: engine out control](https://openairdocs.org/ntsb-findings/01062025): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-findings/01062025/cases.md?model=1152744), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01062025/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 58P, 6 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152744), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=1152744), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md)
- [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=1152744), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md)
- [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Beech 58P, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152744), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 58P, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152744), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/aircraft/N2061K), registered now, S/N TJ-161, built 1978 (OpenAirDocs)
- Reported make and model: BEECH 58P
- Registry model: [Beech 58P](https://openairdocs.org/model/beech-58p) (registry code 1152744) (OpenAirDocs)
- Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: TJ-161
- Year built: 1978
- Engines: Continental TSIO-520-WB 310 hp reciprocating; Continental 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 26; injuries: fatal; 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

## 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 20230317001769A](https://openairdocs.org/incident/20230317001769A), Mar 17, 2023: Beech 58P, Lubbock, TX, Destroyed, 1 fatal. On March 17, 2023, at 1138 CDT, a Beech barron B-58P, bearing registration number[privacy data omitted] was destroyed after it impacted the ground, just after…

## Docket (25 files)

The files NTSB released with the investigation on August 7, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106909.

- FBO surveillance video summary (item 1, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16980061&FileExtension=pdf&FileName=MOR%20FBO%20Surveillance%20Video%20Summary-Rel.pdf
- FBO surveillance video - aircraft arrival on FBO ramp at 1111 (item 2, DAV, 37.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16971869&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317111034_20230317111204-Rel.dav
- FBO surveillance video - pilot and passengers exit aircraft (item 3, DAV, 16.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16971467&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317111216_20230317111252-Rel.dav
- FBO surveillance video - pilot returns for baggage and fuel truck pulls up to aircraft at 1116 (item 4, DAV, 44.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16972360&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317111527_20230317111714-Rel.dav
- FBO surveillance video - fuelling of aircraft completed at 1123 (item 5, DAV, 52.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16971798&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317112157_20230317112403-Rel.dav
- FBO surveillance video - pilot walked out of the FBO building and onto the ramp at 1127 (item 6, DAV, 18.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16972276&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317112736_20230317112818-Rel.dav
- FBO surveillance video - pilot walking around aircraft at 1128 (item 7, DAV, 17.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16972884&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317112818_20230317112855-Rel.dav
- FBO surveillance video - pilot walking around aircraft at 1129 (item 8, DAV, 8.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16972926&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317112855_20230317112910-Rel.dav
- FBO surveillance video - pilot walking around aircraft at 1129 to engine start and taxi (item 9, DAV, 145 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16979922&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317112910_20230317113513-Rel.dav
- FBO surveillance video - aircraft hold short and takeoff runway 35 at 1136-1137 (item 10, DAV): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16970410&FileExtension=dav&FileName=Cleartech%20Aviation_ch1_main_20230317111745_20230317120000-Rel.dav
- FBO surveillance video - aircraft takeoff roll and lift-off (item 11, DAV, 25.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16978332&FileExtension=dav&FileName=Cleartech%20Aviation_ch14_main_20230317113657_20230317113755-Rel.dav
- Surveillance video summary a�� jimmy mclearen (item 12, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16980862&FileExtension=pdf&FileName=MOR%20Surveillance%20Video%20Summary%20%E2%80%93%20Jimmy%20McLearen-Rel.pdf
- Surveillance video of flight - provided by jimmy mclearen (item 13, MOV, 23.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16948357&FileExtension=MOV&FileName=Jimmy%20McLearen%20Video-Rel.MOV
- Automatic dependent surveillance broadcast plot (item 14, KMZ, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16986296&FileExtension=kmz&FileName=20230317_A1AAD2_510329368-Rel.kmz
- Automatic dependent surveillance broadcast data (item 15, XLSX, 8.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16985894&FileExtension=xlsx&FileName=20230317_A1AAD2_510329368_ADSB-Rel.xlsx
- Record of examination (item 16, PDF, 2 pages, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16984015&FileExtension=pdf&FileName=Record%20of%20Examination-Rel.pdf
- EFIS - specialist's factual report (item 17, PDF, 5 pages, 790 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15931945&FileExtension=pdf&FileName=EFIS%20-%20Specialist%27s%20Factual%20Report-CEN23FA139-Rel.pdf
- Personal electronic device - specialist's factual report (item 18, PDF, 3 pages, 223 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16338432&FileExtension=pdf&FileName=Personal%20Electronic%20Device%20-%20Specialist%27s%20Factual%20Report_CEN23FA139-Rel.pdf
- Twin engine initial/recurrent training syllabus completion (item 19, PDF, 4 pages, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16931883&FileExtension=pdf&FileName=AST%20Training%20certificate%20-%20Blake%20Christie_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation - Textron (item 20, PDF, 1 page, 535 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16980117&FileExtension=pdf&FileName=Party%20Form%20Textron%20Master_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation - hartzell propeller (item 21, PDF, 14 pages, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16985874&FileExtension=pdf&FileName=Hartzell%20Party%20Form%20Master_Redacted-Rel.pdf
- Aircraft logbook excerpts (item 22, PDF, 3 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17079939&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Log%20Master_Redacted-Rel.pdf
- Toxicological report (item 23, PDF, 1 page, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17081654&FileExtension=pdf&FileName=Tox%20Master_Redacted-Rel.pdf
- Photos (item 24, PDF, 7 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17080739&FileExtension=pdf&FileName=Photo%20Template-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 25, PDF, 1 page, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17081376&FileExtension=pdf&FileName=NTSB%20Release-%20N2061K_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.

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