ERA12LA295

NTSB accident investigation · Raytheon A36 · Yorktown, NY · April 20, 2012

Accident · Minor injuriesLimited investigationFinal report
Date
April 20, 2012, 16:26 local (20:26 UTC)
Place
Yorktown, NY
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N821SMRaytheon A36
Defining event
Enroute-cruise: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report May 9, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA FSDO, Continental Engines
FAA report
20120420015079A
Case key
83448

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's improper placement of the fuel selector, which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the pilot's failure to perform the published emergency procedure by the checklist.

Findings · 3

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.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationRaytheon A36: 1 caseAll aircraft: 176 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotRaytheon A36: 3 casesAll aircraft: 1,391 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotRaytheon A36: 2 casesAll aircraft: 336 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 airplane was in cruise flight at 7,000 feet when the engine lost power. The pilot requested vectors to the nearest airport but determined the airplane would not reach the requested landing site. He selected a forced landing site on a corporate complex and completed the forced landing, which resulted in substantial damage to the airplane. During the descent, he stated that he performed remedial actions in accordance with the checklist and switched the fuel selector from the right tank position to the left tank. Later, the pilot stated that he did not consult a checklist, but performed emergency action items "from memory." He added that the engine would surge during the descent but would not produce sufficient power to maintain altitude. A witness stated that he saw the airplane at low altitude near the campus and described the engine sound as surging between idle and "extremely high rpm." He said that the engine sounded as though it was "starving for fuel." Examination of the airplane revealed no preimpact mechanical anomalies. The fuel selector was found in a position between the left tank and right tank detents. A detailed examination revealed continuity of the fuel system, unobstructed fuel lines and filters, and an operational fuel selector. The engine was removed from the airplane and placed in a test cell, where it started immediately, accelerated smoothly, and ran continuously without interruption. The engine run revealed no anomalies that would have prevented normal operation and the production of rated power. A warning in the airplane manufacturer's Pilot's Operating Handbook stated: "POSITION [Fuel] SELECTOR IN DETENTS ONLY – NO FUEL FLOW TO ENGINE BETWEEN DETENTS" It is likely that the pilot moved the fuel selector during cruise flight but did not ensure that it was seated correctly in the detent. Shortly thereafter, the engine lost power. Because the pilot did not perform the requisite emergency procedures, he did not recognize that the fuel selector was not seated properly.

Factual narrative

On April 20, 2012, at 1626 eastern daylight time, a Hawker-Beechcraft Corporation A36, N821SM, was substantially damaged during a forced landing following a loss of engine power during cruise flight in Yorktown, New York. The certificated private pilot and passenger sustained minor injuries. The flight departed Teterboro Airport (TEB), Teterboro, New Jersey about 1600, and was destined for Norwood Memorial Airport (OWD), Norwood, Massachusetts. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. In a written statement, the pilot stated that the airplane was in cruise flight at 7,000 feet when the engine lost power. He requested vectors to the nearest airport, but determined the airplane would not reach the requested landing site. He selected a forced landing site on the IBM corporate campus in Yorktown, and completed the forced landing, which resulted in substantial damage to the airplane. During the descent, he stated that he performed remedial actions in accordance with the checklist, and switched the fuel selector from the right tank position to the left tank. He added that the engine would surge during the descent but would not produce sufficient power to maintain altitude. In an interview with a Federal Aviation Administration (FAA) inspector, the pilot stated that he did not consult a checklist during the descent, but performed the emergency action items "by memory." In a telephone interview, a witness stated that he saw the airplane at low altitude near the IBM corporate campus and it appeared to be "in distress." He described the engine sound as surging between idle and "extremely high rpm." He said that the engine sounded as though it was "starving for fuel." According to FAA records, the airplane was manufactured in 1996. The most recent annual inspection was completed July 1, 2011, at 1,460.4 total aircraft hours. At the time of the accident, the airplane had accrued 1,503 total aircraft hours. The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. He reported 383.5 total hours of flight experience, of which 165.5 hours were in the accident airplane make and model. His most recent FAA third-class medical certificate was issued November 9, 2011. Examination of the airplane at the scene by FAA inspectors revealed no pre-impact mechanical anomalies. The fuel selector was found in a position between the left tank and right tank detents . A detailed examination by the inspectors at a recovery facility revealed continuity of the fuel system, unobstructed fuel lines and filters, and an operational fuel selector. The engine was removed from the airplane, and placed in a test cell on May 2, 2012. Prior to the test run, a borescope examination of the engine's cylinders revealed "normal" deposits and wear, and no anomalies. Theengine started immediately, accelerated smoothly, and ran continuously without interruption. The engine run revealed no anomalies that would have prevented normal operation and the production of rated power. A warning in the airplane manufacturer's Pilot's Operating Handbook stated: "POSITION [Fuel] SELECTOR IN DETENTS ONLY – NO FUEL FLOW TO ENGINE BETWEEN DETENTS"

Aircraft

Registration
N821SM
Reported as
Raytheon A36
Category
Airplane
Serial number
E-3031
Airframe hours
1,503
Engine
Cont Motor IO-550 SERIES, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Ehrenzeller Mark
Registered owner
Ehrenzeller Mark
Last inspection
Annual · July 1, 2011 · 43 hours before
Departed
TEB · Teterboro, NJ
Destination
OWD · Norwood, MA
Flight plan
IFR

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
38
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Flight hours
383 total · 165 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 9 knots
Visibility
10 statute miles
Lowest ceiling
4,000 ft broken
Temperature
66 °F, dew point 46 °F
Altimeter
29.95 inHg
Observed at
HPN, 9 nm away

Docket · 10

The files NTSB released with the investigation on March 22, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.7 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.