CHI01LA264

NTSB accident investigation · Beech 23 · West Bend, WI · August 6, 2001

Accident · Minor injuriesLimited investigationFinal report
Date
August 5, 2001, 20:39 local (Aug 6, 2001, 01:39 UTC)
Place
West Bend, WI
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2367JBeech 23
Weather
Visual (VMC) · Day
Status
Completed · report January 2, 2002
Report
Approved by Office Director
Parties
FAA-Milwaukee, Wisconsin FSDO
FAA report
20010805026959A
Case key
52975

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

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Probable cause

The pilot not following the aircraft fuel management procedures. Factors were the fuel starvation, the low altitude, the manufacturers service instruction not complied with, and the tree.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerTakeoff - initial climb
Procedures/directives - not followedPilot in commandCause
Fluid,fuel - starvationFactor
Maintenance,service bulletin/letter - not complied withFactor
Altitude - lowFactor
Forced landingEmergency descent/landing
In flight collision with objectEmergency descent/landing
Object - tree(s)Factor
In flight collision with terrain/waterEmergency descent/landing

Analysis

The airplane lost engine power during the takeoff portion of a touch and go and subsequently impacted a tree and the ground before coming to rest. A postaccident examination showed that the left wing fuel tank was compromised and the right wing fuel tank was intact. Fuel could not be seen in the right fuel tank by visual inspection through the fuel filler opening. Fuel was found in the carburetor fuel bowl. The fuel selector valve was found with the selector positioned for the right wing fuel tank. Four gallons of fuel was added to the right wing fuel tank and an engine run performed. The engine was run from idle to 1,500 RPM and no anomalies were noted. No anomalies were found that could be associated with a preexisting condition. The pilot stated that he began the flight with 10 gallons of fuel in each wing tank and he indicated, in his written report, that there were 20 gallons of fuel on board at the last takeoff. The "Pilot's Operating Handbook and FAA Approved Airplane Flight Manual" for the aircraft states, "Do not take off when the Fuel Quantity Gages indicate in the *Yellow Band or with less than 11 gallons in each main tank." It was found during the postaccident examination of the aircraft that the fuel quantity gages were not marked with yellow bands.

Factual narrative

On August 5, 2001, at 2039 central daylight time, a Beech model 23, N2367J, piloted by a private pilot, sustained substantial damage during a forced landing following a loss of engine power during initial climb after takeoff from runway 24 (3,898 feet by 75 feet), at the West Bend Municipal Airport, West Bend, Wisconsin. The 14 CFR Part 91 personal flight was operating in visual meteorological conditions and was not on a flight plan. The pilot and his one passenger received minor injuries. The local flight originated at about 2000.

A postaccident examination of the aircraft was conducted. The left wing fuel tank was compromised. The right wing fuel tank was intact. Fuel could not be seen in the right fuel tank by visual inspection through the fuel filler opening. Fuel was found in the carburetor fuel bowl. The fuel selector valve was found with the selector positioned for the right wing fuel tank. Four gallons of fuel were added to the right wing fuel tank and an engine run performed. The engine was run from idle to 1,500 RPM and no anomalies were noted. No anomalies were found that could be associated with a preexisting condition.

The pilot said, in a written statement, that he was returning from a 30 minute flight and was performing a touch and go. He said that on the takeoff portion of the touch and go, he experienced a complete loss of engine power approximately 200 feet AGL. He said, "There were several popping sounds from the engine before it quit. I tried to restart but had no success. I chose a relatively open spot in front of me and did my best to keep the aircraft under control. At about 10 feet AGL the left wing contacted a tree. This spun the aircraft sharply and the aircraft landed flat."

The pilot stated to a Federal Aviation Administration Inspector that he began the flight with 10 gallons of fuel in each wing tank. In his written report, the pilot indicated that there were 20 gallons of fuel on board at the last takeoff.

The "Pilot's Operating Handbook and FAA Approved Airplane Flight Manual" for the aircraft states in Section II;

Fuel management

Do not take off when the Fuel Quantity Gages indicate in

the *Yellow Band or with less than 11 gallons in each main

tank.

Maximum slip duration: 30 seconds

*Yellow band was installed by BEECHCRAFT S.I. No. 0624-281.

It was found during the postaccident examination of the aircraft that the fuel quantity gages were not marked with yellow bands.

Aircraft

Registration
N2367J
Reported as
Beech 23
Category
Airplane
Serial number
M-325
Airframe hours
2,415
Engine
Lycoming O-320, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Donald W. McLean
Airworthiness certificate
Standard, Utility
Last inspection
Annual · January 18, 2001 · 53 hours before
Departed
ETB · West Bend, WI
Airport
ETB · West Bend Muni, runway 24, 3,898 × 75 ft, asphalt

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
19
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
July 31, 2000
Seat
Left
Flight hours
130 total · 120 in this make and model · 37 in the last 90 days · 18 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
0° at 0 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 73 °F
Altimeter
30.10 inHg
Observed at
ETB

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 N2367J · 2

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