# NTSB ERA12FA074: Beech 95-C55, N54552, Ulysses, PA, November 17, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: November 17, 2011, 16:19 local (21:19 UTC) - Place: Ulysses, PA - Coordinates: 41.939167, -77.691947 - Nearby events: https://openairdocs.org/map.md?lat=41.9392&lon=-77.6919&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-change of cruise level: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 4 serious - Status: Completed, report August 7, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 82334 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12FA074 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82334/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82334 - Page: https://openairdocs.org/ntsb/ERA12FA074 ## Probable cause The total loss of left engine power due to fuel starvation, and the pilot’s improper configuration of the fuel system during remedial actions, which resulted in fuel starvation of the right engine. Contributing to the accident was the pilot’s incomplete preflight inspection and the pilot’s operation of the airplane with a known faulty fuel quantity indicating system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech 95-C55, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=1152708), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 95-C55, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1152708), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 95-C55, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=1152708), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Fuel system: fuel indication system](https://openairdocs.org/ntsb-findings/01022840): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Beech 95-C55, 1 case](https://openairdocs.org/ntsb-findings/01022840/cases.md?model=1152708), [All aircraft, 30 cases](https://openairdocs.org/ntsb-findings/01022840/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-change of cruise level: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech 95-C55, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1152708), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech 95-C55, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1152708), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 95-C55, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152708), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airplane departed on a cross-country flight with an unknown quantity of fuel. Although the pilot had asked for the main tanks to be filled, it is likely that the fueler did not add enough fuel. According to the pilot, the left main fuel gauge read inaccurately, but the pilot did not check the fuel level during his preflight inspection. Given the flight times since the airplane’s last complete fuel service, its subsequent partial fuel service, and the fuel consumption rates provided by the airplane’s owner, it is likely that the fuel supply in the left main tank was nearly exhausted during the climb after takeoff from the departure airport on the accident flight. The airplane completed the cruise portion of the flight on the auxiliary tanks, and when the fuel selectors were placed back in the main positions, the left engine stopped producing power due to fuel starvation. According to the pilot’s operating manual, the left fuel selector should have been in the main or auxiliary position, and the right fuel selector should have been in the crossfeed position. However, during the left-engine restart attempt, the pilot configured the left fuel selector to crossfeed position and the right fuel selector to the auxiliary position; such a configuration starved the right engine of fuel. When the right engine “surged,” the pilot abandoned the restart and feathered the left propeller. Restart of the right engine was also unsuccessful, and the pilot completed a power-off forced landing. The airplane’s emergency procedures and fuel system schematics revealed that, had the left engine been feathered and the fuel system configured properly by the published procedure, the right engine would have continued to operate on the fuel that remained in the right main fuel tank. ## Factual narrative HISTORY OF FLIGHT On November 17, 2011, about 1619 eastern standard time, a twin-engine Hawker Beechcraft Corporation Model 95-C55 Baron, N54552, impacted a garage during a forced landing following a total loss of engine power near Ulysses, Pennsylvania. The airplane was substantially damaged during the impact sequence and consumed by a post-crash fire. The certificated airline transport pilot and three passengers were seriously injured. The airplane was registered to a corporation and operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that originated from New Castle Airport (ILG), Wilmington, Delaware, around 1500, with the intended destination of Buffalo Airfield (9G0), Buffalo, New York. According to the pilot, the airplane departed ILG after being serviced with 23 gallons of fuel. The airplane was in cruise flight at 8,000 feet mean sea level (msl), when, due to turbulence and rime icing, the pilot requested a descent to 6,000 feet msl. The pilot then switched the fuel selector positions from the auxiliary fuel tank to the main tank on both the left and right selectors because the auxiliary tanks were "empty." Soon after, the left engine began to surge. The pilot switched the fuel selectors back to the auxiliary tanks, and as he attempted to restore the left engine to full power, the right engine surged. As the pilot performed remedial actions to restore power to the right engine, the left engine stopped producing power, and he feathered the left propeller. The right engine experienced a total loss of power seconds after. The pilot then abandoned engine restart attempts to concentrate on control of the airplane. The airplane descended through clouds over mountainous terrain, and descended beneath the clouds to an altitude of only a few hundred feet above the ground. The pilot's first two choices for the forced landing were unavailable, so he "stalled the airplane into the garage" to lessen the impact forces. The airplane collided with and came to rest inside a 50-foot by 75-foot garage and attached workroom. A significant post crash fire ensued, but the occupants were able to egress the airplane and the garage without assistance. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held an airline transport pilot certificate with ratings for airplane single-engine, multiengine, and rotorcraft helicopter. He also held a flight instructor certificate with ratings for airplane single engine and instrument airplane and helicopter. The pilot reported 12,200 total hours of flight experience, of which 1,100 were in the accident airplane make and model. His most recent first class FAA medical certificate was issued February 9, 2011. AIRCRAFT INFORMATION According to FAA and maintenance records, the airplane was manufactured in 1965, and was registeredto a corporation in February 1994. It was a six-place, low wing, multi-engine airplane, with retractable landing gear. According to the airplane’s maintenance records, the most recent annual inspection was completed on September 5, 2011, at 6,027 total aircraft hours. The airplane had a 142-gallon fuel capacity, of which 136 gallons was usable. The inboard (main) fuel tanks contained 40 gallons when full, and the auxiliary (outboard) tanks contained 31 gallons when full. According to the pilot, he performed a preflight inspection at 9G0 on the morning of the accident. At that time the auxiliary fuel tanks were full, and the main fuel tanks were "a little more than half" full. The owner of the airplane stated that on the flight prior to the day of the accident, the airplane had flown approximately 1.3 hours after it was filled with fuel, and that the flight was completed with only the main fuel tanks selected. The airplane then departed 9G0 and flew 1.3 hours to ILG. After landing, the pilot instructed the fixed base operator to "top off the mains." but In a written statement, the FBO manager said his line service technician consulted a more experienced technician before fueling the airplane to ensure that he "was filling the correct tank" and had also checked the outboard [aux] fuel tanks and "noted they were full." In an interview with an FAA inspector after the accident, the technician stated that he had topped the main tanks with approximately 12 gallons of fuel in each main tank, and that he did not check the fuel level in the outboard fuel tanks because his instructions were to top off the main tanks only. Examination of fuel receipts revealed that the airplane was serviced with 23.2 gallons of fuel. Prior to the return flight to 9G0, the pilot ensured that the right main tank was full, but was distracted by aircraft loading that was in progress, and did not visually confirm the fuel level of left main tank. He further stated that the fuel gauge for the left tank was "problematic," and "doesn't read accurately," and that they typically checked the tanks visually for that very reason. The pilot added, "In retrospect I don't think it was topped off because they only gave me 28 gallons of fuel…I should have questioned the line guy why he only put 28 gallons in the plane but I was distracted by [passengers] and it took me off my task." The owner of the airplane stated that the airplane's average fuel consumption rate was 30 gallons per hour. METEOROLOGICAL INFORMATION At 1633, the weather conditions reported at Wellsville Municipal Airport (ELZ), about 18 miles northwest of the accident site, included winds from 290 at 9 knots gusting to 15 knots. There was a broken cloud ceiling at 2,300 feet, and the visibility was 2 miles in light snow. The temperature was -1 degrees C, dew point -4 degrees C, and the altimeter setting was 29.91 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the site, and all major componentsof the airplane were accounted for at the scene. The garage contained four cars as well as several machines, tools, thinners, and other solvents. The fire was fueled by aviation fuel, gasoline, and a coal pile located behind the structure. After the fire, only an outline of the garage structure remained and few identifiable pieces of the airplane were discovered in the debris. The airplane components identified were the outboard sections of the left and right wings, the left and right engines, left and right landing gear supports, four seat frames, main landing gear supports, and throttle quadrant cabling. The fuel selector valves were located and separated from the wreckage and retained for detailed examination. TESTS AND RESEARCH The left and right fuel selector valves were examined in Clayton, Delaware on November 29, 2011. The selector valves were separated from the airframe by post-crash fire, and both were extensively fire-damaged. Each fuel selector controlled a four-position valve. The positions were Main, Auxiliary, Crossfeed, and Off, respectively. Comparison of the valves to technical diagrams provided by the manufacturer revealed which was the right selector valve, and which was the left. Examination of the orientation of the roll pin mounted on the selector handle assembly revealed that the left fuel selector valve was in the "crossfeed" position. Examination of the orientation of the roll pin mounted on the selector handle assembly revealed that the right fuel selector valve was in the "aux" position. According to the manufacturer's Pilot's Operating Manual, the procedure for left engine inoperative on crossfeed was: 1. Right Aux Fuel Pump – ON (LOW) 2. Left Fuel Selector Valve – MAIN OR AUXILIARY 3. Right Fuel Selector Valve – CROSSFEED 4. Right Aux Fuel Pump – LOW or OFF as required. According to a Hawker Beechcraft maintenance manual fuel system schematic, the fuel selectors as found were in a configuration that would feed fuel to the left engine from the right auxiliary fuel tank. ADDITIONAL INFORMATION According to the Pilot’s Operating Manual, the emergency procedure for ENGINE FAILURE AFTER LIFTOFF AND IN FLIGHT, after positive control of the airplane is established: 6. Secure inoperative engine a. Mixture Control – IDLE CUT-OFF b. Fuel Selector – OFF c. Auxiliary Fuel Pump – OFF d. Magneto/Start Switch – OFF e. Alternator Switch – OFF f. Cowl Flap – CLOSED Examination of the fuel system schematic revealed that in this configuration, the fuel system on the side of the operative engine provided fuel to that engine. ## Aircraft - Registration: [N54552](https://openairdocs.org/deregistered/N54552-2013-09-09), registration cancelled 2013-09-09, S/N TE-37, built 1965 (OpenAirDocs) - Reported make and model: BEECH 95-C55 - Registry model: [Beech 95-C55](https://openairdocs.org/model/beech-95-c55) (registry code 1152708) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TE-37 - Airframe hours: 6027 - Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating; CONT MOTOR IO 520 SERIES 285 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Business, Part 91 - Operator: Ekl Leasing Corporation - Registered owner: Ekl Leasing Corporation - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 5, 2011 - Departed: ILG, Wilmington, DE - Destination: 9G0, Buffalo, NY - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: serious; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 20, 2011; seat: left; flight hours: 12,200 total, 1,100 in this make and model, 8,800 as pilot in command, 33 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 290° at 9 knots, gusting 15 - Visibility: 2 statute miles - Lowest ceiling: 2,300 ft broken - Temperature: 30 °F, dew point 25 °F - Altimeter: 29.90 inHg - Observed at: ELZ, 18 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 20111117030359A](https://openairdocs.org/incident/20111117030359A), Nov 17, 2011: Beech 95-C55, Harrison Valley, PA, Destroyed. On November 17, 2011, at approximately 1620 hours eastern time (et), aircraft N54552, a Beechcraft be 95-C55, serial number TE-37, owned by ekl leasing… ## Other investigations on N54552 (1) 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. - [NTSB MIA87LA151](https://openairdocs.org/ntsb/MIA87LA151), Apr 30, 1987: Beech 95-C55 (N54552), Titusville, FL, substantial damage ## Docket (19 files) The files NTSB released with the investigation on June 19, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82334. 31.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366352&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation with Pilot (item 2, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366353&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Pilot-Master.PDF - Record of Conversation with the Pilot (item 3, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370537&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20the%20Pilot-Master.PDF - Record of Conversation with Passengers (item 4, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366376&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Passengers-Master.PDF - Pilot Communications with ATC (item 5, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366378&FileExtension=.PDF&FileName=Pilot%20Communications%20with%20ATC-Master.PDF - Police Report (item 6, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366410&FileExtension=.PDF&FileName=Police%20Report-Redacted.PDF - Fuel Receipt Information (item 7, .PDF, 451 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366392&FileExtension=.PDF&FileName=Fuel%20Receipt%20Information-Redacted.PDF - Airplane Fuel System Description (item 8, .PDF, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366398&FileExtension=.PDF&FileName=Airplane%20Fuel%20System%20Description-Master.PDF - Fuel Selector Examination Notes (item 9, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366551&FileExtension=.PDF&FileName=Fuel%20Selector%20Examination%20Notes-Redacted.PDF - FAA Statement - Airplane Fueler (item 10, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370102&FileExtension=.PDF&FileName=FAA%20Statement%20-%20Airplane%20Fueler-Redacted.PDF - Airplane Before Accident (Courtesy of Flight Aware) (item 11, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366401&FileExtension=.PDF&FileName=Airplane%20Before%20Accident%20(Courtesy%20of%20Flight%20Aware)-Master.PDF - KELZ Weather Observations (item 12, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366403&FileExtension=.PDF&FileName=KELZ%20Weather%20Observations-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366404&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366407&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1: Left Engine (item 15, .PDF, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366427&FileExtension=.PDF&FileName=Photo%201%3A%20Left%20Engine-Master.PDF - Photo 2: Right Engine (item 16, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366428&FileExtension=.PDF&FileName=Photo%202%3A%20Right%20Engine-Master.PDF - Photo 3: View of Accident Site (item 17, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366430&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20Accident%20Site-Master.PDF - Photo 4: View of Left Wing (item 18, .PDF, 6.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366431&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20Left%20Wing-Master.PDF - Photo 5: View of Right Wing (item 19, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366467&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20Right%20Wing-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.