# NTSB CEN23LA406: Beech B200, N220KW, Elk Grove Village, IL, September 8, 2023 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: September 8, 2023, 18:41 local (23:41 UTC) - Place: Elk Grove Village, IL - Coordinates: 42.038956, -88.006186 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.0390&lon=-88.0062&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 193042 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA406 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193042/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193042 - Page: https://openairdocs.org/ntsb/CEN23LA406 ## Probable cause The pilot’s improper fuel planning, that resulted in a total loss of engine power due to fuel exhaustion, and a subsequent forced landing. Also causal was the pilot’s decision to go around with minimum fuel. ## 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 management (probable cause); cases with it: [Beech B200, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1152922), [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 · Fluid level (probable cause); cases with it: [Beech B200, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1152922), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech B200, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1152922), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Beech B200, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=1152922), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) ## Analysis The pilot reported that he had completed a charter flight and departed to pick up new passengers at an airport about 200 nautical miles away. While on approach to the destination airport, the previous passengers notified the pilot that they were ready to be picked up, so the pilot did not land and turned the airplane back toward the departure airport. The pilot climbed to 10,000 ft and noticed the airplane’s fuel burn was high, so he climbed to 16,000 ft. The pilot reported that “everything was routine until about a 3-mile final” to the runway, when the controller asked the pilot to slow to a final approach speed. An airplane was still on the runway, so the controller told the pilot to go around. The pilot told controllers twice that he had minimum fuel available. The pilot continued on a visual approach for the same runway when the right engine lost power followed by the left engine. He feathered both propellers and made a forced landing to a wooded area. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. The pilot reported that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot later stated that he was “trying to do too much with too little” fuel and the accident was a result of poor fuel management. Although the controller directed the pilot to go around, the pilot should have recognized the criticality of the minimum fuel situation and landed the airplane. ## Aircraft - Registration: [N220KW](https://openairdocs.org/aircraft/N220KW), registered now, S/N BB-1120, built 1983 (OpenAirDocs) - Reported make and model: BEECH B200 - Registry model: [Beech B200](https://openairdocs.org/model/beech-b200) (registry code 1152922) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: BB-1120 - Year built: 1983 - Airframe hours: 9817 - Engines: Pratt & Whitney PT6A-42 850 horsepower turbo prop; Pratt & Whitney PT6A-42 850 horsepower turbo prop - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Onyx Flight, Inc, doing business as AirChoice - Registered owner: Airselect LLC - Airworthiness certificate: Standard, Normal - Last inspection: Condition, January 11, 2023 - Departed: ORD, Chicago, IL - Destination: ORD, Chicago, IL - Flight plan: IFR - Airport: ORD, Chicago O'Hare Intl, runway 9L, 7,500 × 150 ft, concrete - Equipment: Auto-pilot, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, Satellite tracking device, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: serious; flight engineer, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review August 21, 2023; seat: left; restraint: lap only; flight hours: 3,394 total, 156.4 in this make and model, 3,252 as pilot in command, 32.7 in the last 90 days, 17.1 in the last 30 days, 1.7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 20° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: 4,400 ft broken - Temperature: 64 °F, dew point 55 °F - Altimeter: 30.10 inHg - Observed at: KORD, 4 nm away - METAR: KORD 082351Z 02011KT 10SM FEW021 BKN044 18/13 A3010 RMK AO2 SLP191 60001 T01830133 10200 20178 50004 ## 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 20230908013419A](https://openairdocs.org/incident/20230908013419A), Sep 8, 2023: Beech B200, Elk Grove Villa, IL, Destroyed. On September 08, 2023, the pilot in command (PIC) operated a 14 CFR part 135 flight carrying two passengers from dane county regional airport (kmsn) to… ## Docket (3 files) The files NTSB released with the investigation on October 17, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193042. 7.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 14 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123227&FileExtension=pdf&FileName=6120%20-%20pilot%20final_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16122884&FileExtension=pdf&FileName=ROC%20-%20Pilot-Rel.pdf - Photos (item 3, PDF, 3 pages, 3 photos, 5.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16123447&FileExtension=pdf&FileName=Photos-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.