# NTSB ERA09LA512: Beech H35, N5469D, Fredericksburg, PA, September 9, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 9, 2009, 14:25 local (18:25 UTC) - Place: Fredericksburg, PA - Coordinates: 40.442779, -76.441665 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.4428&lon=-76.4417&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report June 17, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 74698 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA512 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74698/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74698 - Page: https://openairdocs.org/ntsb/ERA09LA512 ## Probable cause A loss of engine power due to fuel starvation as a result of the pilot's mismanagement of available 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 H35, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151520), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech H35, 3 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151520), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech H35, 3 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151520), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech H35, 7 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151520), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## 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](https://openairdocs.org/deregistered/N5469D-2011-01-03), registration cancelled 2011-01-03, S/N D-4954, built 1957 (OpenAirDocs) - Reported make and model: BEECH H35 - Registry model: [Beech H35](https://openairdocs.org/model/beech-h35) (registry code 1151520) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-4954 - Airframe hours: 6125 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: minor; 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 ## 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 20090909025529A](https://openairdocs.org/incident/20090909025529A), Sep 9, 2009: Beech H35, Fredericksburg, PA, Destroyed. After 20-25 minutes of flight , the engine stopped due to fuel starvation. Subsequent mismanagement of the remaining fuel resulted in a forced landing in a… ## Docket (4 files) The files NTSB released with the investigation on April 14, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74698. 706 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323851&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Excerpts, Beech H35 POH (item 2, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323852&FileExtension=.PDF&FileName=Excerpts,%20Beech%20H35%20POH-Master.PDF - Beech J35 Air Start Procedures (item 3, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324408&FileExtension=.PDF&FileName=Beech%20J35%20Air%20Start%20Procedures-Master.PDF - FAA Inspector Party Review Statement (item 4, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323853&FileExtension=.PDF&FileName=FAA%20Inspector%20Party%20Review%20Statement-Master.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.