ERA09LA512

NTSB accident investigation · Beech H35 · Fredericksburg, PA · September 9, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
September 9, 2009, 14:25 local (18:25 UTC)
Place
Fredericksburg, PA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5469DBeech H35
Defining event
Enroute: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report June 17, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20090909025529A
Case key
74698

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

A loss of engine power due to fuel starvation as a result of the pilot's mismanagement of available fuel.

Findings · 2

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 H35: 4 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotBeech H35: 3 casesAll 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

According to the pilot, he took off with 10 gallons of fuel on board. The pilot operating handbook stated that 10 gallons of fuel in each tank was required. Enroute, the engine lost power, and the pilot performed a forced landing in a residential area about 1,500 feet from an airport runway. An on-scene examination of the wreckage revealed that the fuel selector was on the right tank, and that there was no fuel in either tank, although any remaining fuel from the left tank could have leaked out when the wing separated from the fuselage. The fuel feed system on the airplane provided, depending on power settings, 6 to 25 gallons per hour of fuel return to the left tank, and the airplane flew 20 to 25 minutes. Although the loss of engine power occurred at a relatively low altitude, there was no evidence that the pilot attempted to utilize the fuel remaining in the left tank either before or after the event.

Factual narrative

On September 9, 2009, about 1425 eastern daylight time, a Beech H35, N5469D, was substantially damaged during a forced landing in Fredericksburg, Pennsylvania. The certificated private pilot sustained minor injuries. Visual meteorological conditions prevailed. No flight plan had been filed for the local flight, which departed Dee Jay Airport (8PA1), Ono, Pennsylvania. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the pilot, the airplane experienced a total engine failure. The pilot also stated that he had taken off with 10 gallons of fuel onboard, and that the engine failure occurred at 1,500 feet above mean sea level (msl), but did not provide any further narrative details of the event. News reports indicated that the airplane landed in a back yard, and a news photograph of the wreckage revealed no apparent damage to the propeller. Mapping out the position of the accident site relative to Farmers Pride Airport (9N7), Fredericksburg, Pennsylvania, revealed that it was approximately in line with, and about 1,500 feet from the runway 28 threshold. According to a Federal Aviation Administration (FAA) inspector, the airplane had flown 20 to 25 minutes prior to the accident. His examination of the airplane at the accident scene revealed that the left wing was separated from the fuselage, and that neither wing had any notable amount of fuel in it. However, some fuel could have drained from the left wing prior to the inspector’s arrival at the scene due to how it came to rest. The inspector also found the fuel selector on the right tank, and did not note any mechanical anomalies with the airplane. Terrain elevation in area of the accident was about 500 feet msl. The airplane’s pilot operating handbook (POH) states, “It is the pilot’s responsibility to ascertain that the fuel quantity indicators are functioning and maintaining a reasonable degree of accuracy, and be sure of ample fuel for a flight. A minimum of 10 gallons of fuel is required in each main tank before takeoff.” The POH further states, “if the pilot is not sure that at least 10 gallons are in each tank, add necessary fuel so the amount of fuel will be not less than 10 gallons per tank at takeoff. Plan for an ample margin of fuel for any flight.” According to the FAA inspector, the airplane’s original carburetor fuel feed system for a Continental O-470-G engine, was replaced with a Continental Continuous Flow Fuel Injection System, the same utilized in later Continental IO-470-C engines. Excess fuel was returned to the left main fuel tank, and according to the fuel pump overhaul manual, at 1,600 engine rpm, at a rate of about 6 gallons per hour, and at 2,600 rpm, at a rate of about 25 gallons per hour. As part of the installation, the original wobble fuel pump was replaced by an electric boost pump. Air Start Procedures for the accident airplane were not available. Air Start Procedures for the Beech J35, with a similar fuelinjection installation, included: “Immediately on noting any condition which would point to imminent engine failure, such as loss of power, loss of fuel pressure, rough running engine, etc., slow the airplane down, and if altitude permits, proceed as follows: a. Switch fuel tanks. NOTE: Many engine failures are the result of fuel starvation due to fuel planning. Look at the fuel selector valve handle when switching tanks to avoid inadvertently switching into the OFF position, or an empty tank. b. Switch on boost pump. c. Throttle – open about 1/2 inch beyond present setting. d. Mixture control – check – full rich. e. Propeller – full high rpm. f. Check ignition switch BOTH, battery and generator switches ON.” The pilot, age 73, held a private pilot certificate with an airplane single-engine land rating. He reported 1,003 hours of total flight time, with 760 hours in make and model.

Aircraft

Registration
N5469D
Reported as
Beech H35
Category
Airplane
Serial number
D-4954
Airframe hours
6,125
Engine
Cont Motor O-470 SERIES, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 5, 2009
Departed
8PA1 · Ono, PA
Destination
8PA1 · Ono, PA
Airport
9N7 · Farmers Pride

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
73
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3
Last flight review
October 5, 2006
Seat
Left
Flight hours
1,003 total · 760 in this make and model · 4 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 6 knots
Visibility
10 statute miles
Lowest ceiling
14,000 ft overcast
Temperature
72 °F, dew point 64 °F
Altimeter
30.15 inHg
Observed at
MDT, 20 nm away

Docket · 4

The files NTSB released with the investigation on April 14, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 706 KB 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.