# NTSB ERA12LA571: Beagle B206 Series 2, N26GW, Perry, FL, September 21, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 21, 2012, 12:45 local (16:45 UTC) - Place: Perry, FL - Coordinates: 29.809722, -83.545555 - Nearby events: https://openairdocs.org/map.md?lat=29.8097&lon=-83.5456&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed, report September 30, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: AAIB, FAA / FSDO - NTSB case key (mKey): 85110 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA571 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85110/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85110 - Page: https://openairdocs.org/ntsb/ERA12LA571 ## Probable cause The pilot’s improper in-flight fuel management, which resulted in fuel starvation and the right engine’s complete loss of power. Contributing to the accident was the pilot’s improper configuration of the airplane following the loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1121224), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1121224), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=1121224), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=1121224), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=1121224), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/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: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=1121224), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=1121224), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=1121224), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=1121224), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-cruise: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=1121224), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=1121224), [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: [Beagle B.206 SERIES 2, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=1121224), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis According to the pilot, before the flight, he performed a preflight inspection on the twin-engine airplane, during which he checked the fuel quantity onboard the airplane by looking at the fuel computer, which displayed 65 gallons. He then added 20 gallons of fuel to the left wing fuel tank and 25 gallons to the right wing fuel tank. He then entered the added amount of fuel into the fuel computer for a total of 110 gallons, which was consistent with the fuel gauges, which display fuel in pounds and which indicated that 275 pounds of fuel was in the left tank and 350 pounds of fuel was in the right tank. This amount should have been sufficient for the flight. After departure, the pilot turned toward his destination and climbed the airplane to about 3,000 feet above sea level. Later, the right engine began to surge, and "after going through the checklist" the pilot elected to do a precautionary landing. The pilot asked air traffic control for the closest airfield; however, the pilot, after seeing nothing but trees, decided to land on a road with the landing gear in the up position. During the landing, the left wingtip struck a tree. Examination of the wreckage revealed that both propellers were in the feathered position, the wing flaps were up, the landing gear was up, and the wing structure and both firewalls were substantially damaged. Further examination revealed that the left wing fuel tank contained about 22 gallons of fuel, and the right wing fuel tank was almost devoid of fuel. Thus, it is likely that the pilot did not monitor the fuel balance and allowed an imbalance between the two fuel tanks to occur, which resulted in the right engine being starved of fuel. This could have been remedied at any time during the cruise portion of the flight if the pilot had opened the cross-feed valve for the right engine, which would have allowed the right engine to feed fuel from the left tank and would have allowed him to balance the fuel load. Examination of the cockpit switches revealed that the airplane had not been properly configured by the pilot for one-engine-inoperative flight per the guidance contained in the operating manual. If this had been done, the the airplane could have continued to fly at altitude, allowing the pilot to reach a diversionary airport and execute a one-engine-inoperative landing. ## Factual narrative The accident aircraft was a low wing, twin engine airplane of conventional metal construction. It was equipped with retractable landing gear, and multiple position wing flaps. It was powered by two 340 horsepower, Continental GTSIO-520-C engines, each equipped with a Hartzell, 3-blade, fully feathering, constant speed propeller. According to the United Kingdom Civil Aviation Authority, the airplane design had been certificated in their Performance Group C, indicating that the airplane had positive en-route performance with one engine inoperative. According to FAA and airplane maintenance records, the airplane was manufactured in 1969. The airplane's most recent annual inspection was completed on March 23, 2012. At the time of accident, the airplane had accrued approximately 3,190 total hours of operation. On September 21, 2012 about 1245 eastern daylight time, a twin engine, Beagle B206 Series 2, N26GW, was substantially damaged during an emergency landing after a loss of power in the right engine in Perry, Florida. Visual meteorological conditions prevailed and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The certificated commercial pilot and his five passengers were not injured. The flight destined for Tallahassee Regional Airport (TLH), Tallahassee, Florida, originated from Placid Lakes Airport (09FA), Lake Placid, Florida about 1140. According to the pilot, at approximately 0830 he performed a preflight inspection on the airplane for the flight to TLH. During the preflight he checked the fuel quantity onboard the airplane by looking at the fuel computer installed in the airplane. It displayed 65 gallons. He then added 20 gallons of fuel to the left wing fuel tank and 25 gallons to the right wing fuel tank. He then entered the added amount of fuel to the existing fuel that was displayed on the fuel computer for a total of 110 gallons which was consistent with the fuel gauges which display fuel in pounds and which indicated that 275 pounds of fuel was in the left tank and 350 pounds of fuel was in the right tank. After departure from 09FA, the pilot turned towards TLH and climbed the airplane to approximately 3,000 feet above sea level. About 1240 while over the Gulf of Mexico, the right engine began to surge and "after going through the checklist" the pilot elected to do a "precautionary landing" as he was offshore. After turning east towards shore, the pilot asked Jacksonville Air Route Traffic Control Center for the closest airfield. However, the pilot after seeing nothing but trees decided to land on a road with the landing gear in the up position. During the landing the left wingtip struck a tree. The recorded weather at Perry-Foley Airport (40J), Perry, Florida, located approximately 16 nautical miles north of the accident site, at 1253, included: winds variable at 3 knots, 10 miles visibility, clear, temperature 27 degrees C, dew point 21 degrees C, and an altimeter setting of 30.03inches of mercury. According to Federal Aviation Administration (FAA) and pilot records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. His most recent FAA third-class medical certificate was issued on February 16, 2011. He reported that he had accrued approximately 2,560 hours of total flight experience, 1,020 hours of which was in the accident airplane make and model. Review of the Operating Handbook for the airplane revealed that the fuel system consisted of left and right fuel tanks each supplying its associated engine through a "booster pump" (boost pump), "cross-feed cock" (cross-feed valve), and a filter. Each tank had a capacity of 117 gallons, 114 of which was usable. When required, either tank could feed the opposite engine by operation of the cross-feed cocks, but both tanks could not feed one engine simultaneously. The operating handbook provided guidance regarding unequal fuel feeding stating that: "Should unequal feeding occur as shown by the readings on the fuel contents gauges, the fuel cock on the low side should be selected to feed from the high side until balanced is restored." The operating handbook also contained an emergency procedures section which provided guidance regarding engine failure, fuel pump failure, and landing with one engine inoperative. Comparison of the required positions of the cockpit controls in the emergency procedures section to the as found position of the cockpit controls in the airplane revealed that the mixture control for he inoperative engine was not in the required position, the engine cooling flap for the inoperative engine was not in the required position, the fuel selector was not in the required position, and the wing flaps were not in the required position. Review of performance information contained in the Operating Handbook indicated that if the airplane had been configured per the guidance in the emergency procedures section, the airplane would have been able to remain at altitude. Examination of the wreckage revealed that both propellers were in the feathered position, the wing flaps were up, and the landing gear was up. The wing structure, engine firewalls, engine nacelles, elevator, and landing gear doors, were substantially damaged. Further examination revealed that the left wing fuel tank contained approximately 22 gallons of fuel. However the right wing fuel tank was almost devoid of fuel. No fuel could be drained from its aft drain, and only about 4 ounces of fuel was able to be drained out of its forward drain. Examination of the cabin revealed that the wing flaps switch was in the up position, the landing gear switch was in the up position, the magneto switches were off, the boost pump switches were off, the engine vents switches were in the open position, the left engine and right engine mixture controls were in the full rich position, the left engine fuel selector was in the lefttank position, and the right engine fuel selector was in the right tank position. ## Aircraft - Registration: [N26GW](https://openairdocs.org/deregistered/N26GW-2014-09-23), registration cancelled 2014-09-23, S/N B206-070 (OpenAirDocs) - Reported make and model: BEAGLE B206 SERIES 2 - Registry model: [Beagle B.206 SERIES 2](https://openairdocs.org/model/beagle-b-206-series-2) (registry code 1121224) (OpenAirDocs) - Category: Airplane - Serial number: B206-070 - Year built: 1969 - Airframe hours: 3190 - Engines: Continental GTSIO-520C 340 horsepower reciprocating; Continental GTSIO-520C 340 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 23, 2012, 10 hours before - Departed: 09FA, Lake Placid, FL - Destination: TLH, Tallahassee, FL - Equipment: Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review August 10, 2011; seat: left; restraint: lap only; flight hours: 2,560 total, 1,020 in this make and model, 2,000 as pilot in command, 3 in the last 90 days, 2 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 70 °F - Altimeter: 30.03 inHg - Observed at: 40J, 15 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 20120921022759A](https://openairdocs.org/incident/20120921022759A), Sep 21, 2012: Beagle B.206 SERIES 2, Perry, FL, Substantial damage. Aircraft suffered loss of power from the right engine at 3000 feet. Pilot elected to perform an emergency landing on a dirt road with both engines caged and… ## Docket (15 files) The files NTSB released with the investigation on August 13, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85110. 16.2 MB in all. - Three View Drawing (item 1, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415013&FileExtension=.PDF&FileName=Three%20View%20Drawing%20-Master.PDF - NTSB Form 6120 (item 2, .PDF, 645 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415014&FileExtension=.PDF&FileName=NTSB%20Form%206120-Redacted.PDF - Witness Statements and Interview Summaries (item 3, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415015&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Redacted.PDF - Map of Accident Area (item 4, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415016&FileExtension=.PDF&FileName=Map%20of%20Accident%20Area-Master.PDF - Weather Reports and Records – K40J METARs (item 5, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415017&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20%E2%80%93%20K40J%20METARs-Master.PDF - Fuel Receipt (item 6, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415018&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Excerpts from B.206 Operating Handbook – Fuel System (item 7, .PDF, 474 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415019&FileExtension=.PDF&FileName=Excerpts%20from%20B.206%20Operating%20Handbook%20%E2%80%93%20Fuel%20System-Master.PDF - Excerpts from B.206 Operating Handbook – Emergency Procedures (item 8, .PDF, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415020&FileExtension=.PDF&FileName=Excerpts%20from%20B.206%20Operating%20Handbook%20%E2%80%93%20Emergency%20Procedures-Master.PDF - Excerpts from B.206 Operating Handbook – Single Engine Climb and Cruise Performance (item 9, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415021&FileExtension=.PDF&FileName=Excerpts%20from%20B.206%20Operating%20Handbook%20%E2%80%93%20Single%20Engine%20Climb%20and%20Cruise%20Performance-Master.PDF - Wreckage Release and Evidence Control Forms (item 10, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415025&FileExtension=.PDF&FileName=Wreckage%20Release%20and%20Evidence%20Control%20Forms-Redacted.PDF - Photo 1 – Main Wreckage (item 11, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415026&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Main%20Wreckage-Master.PDF - Photo 2 – Close Up of Main Wreckage (item 12, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415027&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Close%20Up%20of%20Main%20Wreckage-Master.PDF - Photo 3 – Wing Comparison (item 13, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415028&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Wing%20Comparison-Master.PDF - Photo 4 – Instrument Panel Showing Position of Mixture, Flap, and Engine Controls (item 14, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415029&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Instrument%20Panel%20Showing%20Position%20of%20Mixture,%20Flap,%20and%20Engine%20Controls-Master.PDF - Photo 5 – Throttle Quadrant Showing position of fuel Selectors, Flaps, and Engine Vents controls (item 15, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415030&FileExtension=.PDF&FileName=Photo%205%20%E2%80%93%20Throttle%20Quadrant%20Showing%20position%20of%20fuel%20Selectors,%20Flaps,%20and%20Engine%20Vents%20controls%0D%0A-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.