ERA09LA108

NTSB accident investigation · Beech E18S · Fort Myers, FL · December 27, 2008

Accident · Serious injuriesLimited investigationFinal report
Date
December 27, 2008, 15:21 local (20:21 UTC)
Place
Fort Myers, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N7765NBeech E18S
Defining event
Initial climb: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report August 12, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/ FSDO
FAA report
20081227856829A
Case key
73141

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 failure of the right propeller to go to the feathered position for undetermined reasons following a total loss of right engine power during initial climb due to fuel starvation as a result of the pilot's improper fuel planning.

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech E18S: 1 caseAll aircraft: 1,695 cases
Propeller system: propeller feather/reversingAircraft › Aircraft propeller/rotor · FailureBeech E18S: 1 caseAll aircraft: 26 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedBeech E18S: 1 caseAll aircraft: 2,247 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotBeech E18S: 1 caseAll aircraft: 719 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 was departing on the fourth and final flight of the day. The pilot checked the fuel quantity using the fuel quantity gauge in the cockpit prior to departure and estimated that the airplane had approximately 100 gallons of fuel. During the initial climb, immediately following gear retraction and power adjustment, the right engine experienced a total loss of power. He switched the fuel selector from the right main fuel tank to the right auxiliary wing fuel tank, and then back to the right main fuel tank; however, he was unable to restore engine power. He also unsuccessfully attempted to feather the right propeller. The pilot had not accelerated the airplane to optimal single-engine rate of climb speed. Unable to maintain altitude, the airplane impacted trees and came to rest facing the opposite direction of travel. Examination of the fuel tanks revealed that the main wing fuel tanks were void of fuel and had not been ruptured. The auxiliary fuel tanks were ruptured but had evidence of fuel, and the rear auxiliary tank contained fuel of an unknown quantity. Examination of the engine, fuel selector valves, propeller, and engine feathering oil pump revealed no mechanical malfunctions that would have prohibited normal operation. The carburetor for the right engine was void of fuel. According to the airplane flight manual, the main fuel tanks must be used "for takeoffs, landing, and flight through rough air." The manual also indicated that the auxiliary tanks should be selected only in cruise flight.

Factual narrative

HISTORY OF FLIGHT On December 27, 2008, about 1521 eastern standard time, a Beech E18S, N7765N, was substantially damaged during a forced landing in a wooded area, shortly after takeoff from Florida Southwest International Airport (RSW), Ft. Myers, Florida. The certificated airline transport pilot was the sole occupant on board and was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the executive/business repositioning flight from RSW to Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, Florida. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. During a phone interview with the pilot, he stated that earlier in the day he had each main and auxiliary fuel tanks filled at FXE. The fueling would have provided him with 270 gallons of fuel; the rear tank in each wing had some fuel, but he did not use the rear tanks to supply fuel to the engines. He flew from FXE to RSW, to pick up the owner of the airplane and several passengers. After he picked up his passengers, he departed from RSW approximately 1130, destined for FXE. About 1500, the airplane returned to RSW, four passengers were unloaded and the pilot was preparing to depart on a return flight to FXE. He stated that prior to departure, he had checked the fuel quantity in each tank via the fuel gauges. The two main tanks and the two wing auxiliary tanks each registered "3/10's fuel." He departed runway 6 and after rotation, while flying at 100 feet above ground level, he raised the landing gear and reduced the engines' power from a takeoff power setting to a cruise/climb power of 30 inches manifold pressure and 2,000 rpm. He then noticed that the right engine had lost power. He attempted to feather the right propeller using the feather switch located on the right side of the instrument panel in front of the other pilot seat. He stated that the right propeller did not feather and at that time, he "had not accelerated to blue line airspeed." He switched the fuel selector from the main tank position, to the auxiliary fuel tank position, back to the right main tank position; however, he was not able to restore engine power. He further reported that "all of this occurred within one minute of take-off." The pilot was unable to maintain altitude and the airplane impacted trees. He stated that after the airplane came to a stop, he turned the magnetos and master switch to the OFF position, and exited the airplane through the main cabin entry door. According to fuel receipts from a fixed based operator located at FXE, the airplane was last fueled with 170.7 gallons of aviation gasoline on December 7, 2008. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate, with ratings for airplane multiengine land, airplane multiengine sea, and instrument airplane. He held a commercial pilot certificate, with ratings for airplane single-engine land, airplane single-engine sea, and glider. His mostrecent Federal Aviation Administration (FAA) first-class medical certificate was issued May 8, 2008. He reported approximately 14,000 total hours of flight experience; of which, 195 hours were in the accident aircraft make and model. AIRCRAFT INFORMATION The airplane had been manufactured in 1959 and had undergone an annual inspection on February 1, 2008. At that time, the airplane had accrued 9,193 total hours of flight time. The airplane was equipped with two Pratt and Whitney R-9085AN-14B engines, which had been overhauled about 1 year prior to the accident. The left engine had accrued 74 total hours since overhaul and the right engine had accrued 82 total hours since overhaul. According to the airplane's flight log, on the day of the accident, the airplane had flown three flights totaling 2.5 hours of flight time. Prior to the day of the accident, the airplane had last flown on December 7, 2008. WRECKAGE AND IMPACT INFORMATION Examination of the airplane by an FAA inspector revealed that the left engine had separated from the left wing and was located approximately 40 yards from the wreckage, near the first tree strike, and the left propeller exhibited no signs of damage. The right engine was still attached to the right wing and the right propeller exhibited signs of tip damage. The airplane had impacted a tree, rotated, and came to rest facing the opposite direction of travel. The empennage was twisted approximately 90 degrees. Control continuity was verified for all control surfaces. The left wing exhibited signs of leading edge crushing. Examination of the cockpit revealed that the throttle levers were full forward, the left propeller lever was approximately three-fourths forward and the right propeller lever was approximately one-fourth forward. Both mixture controls were one-fourth forward, the left fuel selector was in the forward position and the right fuel selector was in the OFF position. The auxiliary wing fuel tanks were ruptured, but there was evidence of fuel. The main wing fuel tanks were void of fuel and the rear auxiliary wing fuel tanks contained some fuel. TESTS AND RESEARCH Examination of the engines by a local airframe and powerplant mechanic, with FAA oversight, revealed no external damage. No contaminations were found in the oil filter assembly, fuel screens located on the airframe, the fuel screen assemblies located in the carburetor for both engines. Additionally, no fuel was found in the carburetor for the right engine. The spark plugs for both engines were examined and appeared normal. The supercharger impeller for the right engine supercharger was checked and operated at that time. The oil lines to the propeller and propeller governor were secure and in place. The fuel control levers were inspected and operated normally. Examination of the right engine feathering oil pump was conducted after recovery of the aircraft. The examination concluded that all items tested, including the right engine feathering oil pump,"appeared to function normally and as anticipated." According to the airplane flight manual (AFM) for the accident airplane model, the main fuel tanks were equipped with electric, submerged boost pumps, and have sufficient capacity to supply the engines at take-off power should the engine-driven fuel pumps fail. The manual also states that "fuel should be used first from the auxiliary tanks, so that the main tanks are available for take-off, landing and flight through rough air." The Pre-Start Checklists states that the "fuel selector valves on to main tanks." The Cruise portion of the manual states in part "Then set up cruising power best suited to your situation…The fuel boost pumps should be turned off, the fuel selector handles switched to use fuel as required…" In Section IV of the AFM, under the section titled "Single-Engine Operation," states in part "The optimum single-engine rate-of-climb speed at sea level is 116 mph IAS [Indicated Air Speed] ("blue line" on the airspeed indicator). Maintaining this speed is of extreme importance if best aircraft performance is to be attained during stimulated or actual emergency conditions."

Aircraft

Registration
N7765N
Reported as
Beech E18S
Category
Airplane
Serial number
BA-413
Airframe hours
9,193
Engines
Pratt & Whitney R-985AN-14B, 450 horsepower, reciprocatingPratt & Whitney R-986AN-14B, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
North American Leasing LLC
Registered owner
North American Leasing LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2008
Departed
RSW · Fort Myers, FL
Destination
FXE · Ft. Lauderdale, FL
Airport
RSW · Southwest Florida Internationa, runway 06, 12,000 × 150 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
51
Injuries
Serious
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land, Multi-engine sea, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 9, 2007
Seat
Left
Flight hours
14,000 total · 195 in this make and model · 13,000 as pilot in command · 86 in the last 90 days · 32 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 14 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 61 °F
Altimeter
30.18 inHg
Observed at
RSW, 1 nm away

Docket · 11

The files NTSB released with the investigation on June 10, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 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.