ERA14FA074

NTSB accident investigation · Raytheon G36 · Panama City, FL · December 18, 2013

Accident · FatalField investigationFinal report
Date
December 18, 2013, 07:20 local (13:20 UTC)
Place
Panama City, FL
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N89SNRaytheon G36
Defining event
Enroute-cruise: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed · report January 7, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Textron Aviation, Continental Motors
FAA report
20131218024549A
Case key
88565

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 inadequate preflight and inflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the pilot’s injuries was his failure to use the available shoulder harness.

Findings · 4

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 levelRaytheon G36: 1 caseAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotRaytheon G36: 1 caseAll aircraft: 719 casesProbable cause
Equipment/furnishings: emergency equipmentAircraft › Aircraft systems · Not used/operatedRaytheon G36: 1 caseAll aircraft: 10 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotRaytheon G36: 1 caseAll aircraft: 792 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 flight was about 60 miles from the destination airport when the pilot reported a total loss of engine power to air traffic control. The controller provided information on nearby airports, and the pilot maneuvered the airplane toward the closest airport. The pilot reported the airport in sight; radio and radar contact were subsequently lost. A search for the airplane was initiated, and the wreckage was located in a heavily wooded swamp about 1 mile east of the airport. There were no known witnesses to the accident. The fuel tank selector handle was found in the "left main" (left wing tank) position. The left wing tank was not breached, and about 1 pint of fuel was recovered from the tank. The right tank was breached, and it contained residual fuel; however, there was no evidence of fuel leakage on the ground beneath the tank. The airplane was fitted with optional wing tip tanks, which were found empty. The total amount of fuel recovered, including the residual fuel in the tanks and fuel recovered from a small pool of water directly under the airplane, was about 2.5 gallons, which was less than the manufacturer-reported unusable fuel quantity of 6 gallons. The airplane was last serviced with fuel about 28 days before to the accident; however, the total fuel onboard at that time could not be determined. The propeller blades exhibited no rotational damage or signatures. After the accident, the engine was removed from the airframe and successfully test run at the manufacturer's facilities; no evidence of pre-accident malfunction or failure was observed. Although a shoulder harness was available, the pilot was found in the left seat with only his lap belt fastened. Damage to the airplane's multi-function display was consistent with impact by the pilot's head during the accident sequence. The pilot's cause of death was blunt force head trauma, and the impact forces that he experienced would likely have been reduced if he had been wearing his shoulder harness.

Factual narrative

The airplane was a Raytheon Aircraft Company model G36 that was manufactured in 2006. It was powered by a Continental IO-550B engine, rated at 300 horsepower at 2,700 rpm and was equipped with a Hartzell three-bladed constant speed propeller. The Hobbs time recorded at the accident site was 734.2 hours. The last annual inspection on the airframe and engine occurred on August 22, 2013 at an airframe total time of 683.0 hours Hobbs time. The last recorded maintenance included Garmin G1000 upgrades on October 3, 2013 at Hobbs time 722.8 hours. No recorded flight and engine data was obtained from the G1000 system as the Secure Digital (SD) card required to record such data was not installed. On December 18, 2013, about 0720 central standard time (CST), a Raytheon Aircraft Company model G36, N89SN, impacted trees and terrain during a forced landing attempt near Panama City, Florida. The airline transport pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to and operated by Grey Aviation, Inc. as a business flight. Day, visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from North Palm Beach County General Aviation Airport (F45), West Palm Beach, Florida about 0554 eastern standard time (0454 CST) and was destined for Destin-Fort Walton Beach, Florida (DTS). The flight was about 60 miles from the destination airport when the pilot reported to Tyndall air traffic control (ATC) that he had lost all engine power. The controller provided information on nearby airports and the pilot maneuvered the airplane in the direction of Sandy Creek Airpark (75FL), a fly-in community. The pilot reported the airport in sight and radio and radar contact was eventually lost. A search for the airplane was initiated, and the wreckage was located in a heavily wooded swamp about one mile east of 75FL. There were no known witnesses to the accident. A postmortem examination of the pilot was performed at the offices of the District 14 Medical Examiner, Panama City, Florida, on December 20, 2013. The autopsy report noted the cause of death as "Blunt Force Head Trauma" and the manner of death was "Accident." Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated no carbon monoxide in the blood, and no ethanol was detected in the vitreous. Cyanide testing was not performed. Dextromethorphan was detected in the blood but not in the urine. Dextromethorphan (Robitussin®, Delsym®, Sucrets®, Bromfed-DM®, Tylenol Cold®, NyQuil®) is an over-the-counter cough suppressant also found in prescription cough medications. It is metabolized into dextrorphan, which also has cough suppressant properties. Ibuprophen was detected in the urine. This medication is an over-the-counterNon-Steroidal Anti-Inflammatory Drug (NSAID). It is used as an anti-inflammatory medication to treat aches and pains, as an antipyretic to reduce fever. The 0658 CST surface weather observation for Tyndall Air Force Base (PAM), located about 5 miles southwest of the accident site, included sky clear, wind from 020 degrees at 9 knots, visibility 10 statute miles or greater, and altimeter setting 30.32 inches of mercury. The pilot held an airline transport pilot certificate with ratings for airplane single engine land and airplane multi-engine land. He reported a total flight experience of 5,000 hours, including 50 hours during the last six months, on his class 1 medical certificate application, dated March 20, 2013. The medical certificate included a restriction to wear corrective lenses for near and distant vision. According to the airplane's owner, the accident pilot was the sole pilot of the airplane since its purchase. The airplane was purchased by its present owner on August 28, 2013. Since then, according to an aircraft flight logbook, about 53.5 hours of flying time had accumulated at the time of the accident. First responders noted that the pilot's lap belt remained attached and he was seated in the left cockpit seat; however, he was slumped forward and to his right. The pilot's shoulder harness was not attached and was undamaged. Engine Examination and Test Run The engine was examined at the Continental Motors facility at Mobile, Alabama on April 8 and 9, 2014. Due to minimal impact damage, a test run was attempted and the engine was not disassembled. Prior to the test run, the engine oil cooler was removed and replaced due to impact damage. Dried mud was removed from the intake system. The engine contained about 11 quarts of oil. The spark plugs were cleaned of rust due to prolonged storage prior to the test run. The plugs operated normally on a test bench. After installation in a test cell, the engine started on the first attempt. The engine ran smoothly and without hesitation at an array of throttle settings from idle through full throttle (2,648 RPM observed). All engine parameters were observed to be in the normal operating range. Magneto checks were normal. Fueling History According to a flight logbook recovered from the wreckage, the airplane was parked at Tampa International Airport (TPA), Tampa, Florida from November 17-22, 2013. On November 22, 18.2 gallons of 100 octane low lead (100LL) aviation gasoline were purchased at a fixed base operator (FBO) at TPA. This was the last known record of a fuel purchase for N89SN prior to the accident. The airplane arrived at F45 on November 22 following a direct flight from TPA and remained there until the initiation of the accident flight on December 18. According to personnel at F45, no fuel was purchased for the accident airplane between November 22 and December 18. According to the flight logbook and the Hobbs meter on the airplane, the airplane departed TPA at 729.9 Hobbs time. TheHobbs time recorded at the accident site was 734.2 hours (4.3 hours elapsed since last fueling). Although the amount of fuel purchased on November 22 was known, the amount of fuel on board the airplane after the last refueling could not be determined. ATC Transcript of Communications According to a transcript of communications provided by Tyndall ATC, the pilot, at 0715:36, stated, "We're losing uh oil here for some reason." A copy of the audio transmission was also provided to investigators. The audio file was then forwarded to the NTSB Vehicle Recorders lab for examination. Their assessment was that the term "oil" referred to by ATC was deemed unintelligible.

Aircraft

Registration
N89SN
Reported as
Raytheon G36
Category
Airplane
Serial number
E-3738
Built
2006
Airframe hours
734
Engine
Continental IO-550B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Grey Aviation Advisors & Solutions Inc
Registered owner
Grey Aviation Advisors & Solutions Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 22, 2013 · 51 hours before
Departed
F45 · West Palm Beach, FL
Destination
DTS · Destin, FL
Flight plan
IFR
Airport
75FL · Sandy Creek Airpark, runway 27, 3,850 × 150 ft
Equipment
Stall warning system, Electronic primary flight display, Electronic multifunction display, Auto-pilot

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
52
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
5,000 total · 53 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 39 °F
Altimeter
30.31 inHg
Observed at
PAM, 5 nm away

Docket · 27

The files NTSB released with the investigation on December 17, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.8 MB in all.

Transcript of Communications - Tyndall AFB ATCItem 1 · .PDF · 1.5 MBAirplane Flight Log ExcerptItem 2 · .PDF · 149 KBMaintenance Logbooks ExcerptsItem 3 · .PDF · 519 KBFuel RecordsItem 4 · .PDF · 213 KBMemorandum for Record - Recent Fueling at F45Item 5 · .PDF · 119 KBBay County Sheriff Incident ReportItem 6 · .PDF · 245 KBEngine Operational Test LogItem 7 · .PDF · 30 KBFlight Path and Accident Site DiagramsItem 8 · .PDF · 319 KBToxicological ReportItem 9 · .PDF · 113 KBCertification of Party RepresentativeItem 10 · .PDF · 275 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 11 · .PDF · 68 KBEvidence ControlItem 12 · .PDF · 83 KBPhoto 1 - Main WreckageItem 13 · .PDF · 1.2 MBPhoto 2 - EmpennageItem 14 · .PDF · 1.1 MBPhoto 3 - Fuselage and EmpennageItem 15 · .PDF · 1.0 MBPhoto 4 - Propeller Blade and Engine CompartmentItem 16 · .PDF · 991 KBPhoto 5 - Engine CowlingItem 17 · .PDF · 1.0 MBPhoto 6 - Engine Compartment and Engine, Cowling OpenedItem 18 · .PDF · 864 KBPhoto 7 - Left Wing InboardItem 19 · .PDF · 852 KBPhoto 8 - Forward Fuselage and Left WingItem 20 · .PDF · 1.0 MBPhoto 9 - Left WingItem 21 · .PDF · 1.1 MBPhoto 10 - Main Wreckage, Right SideItem 22 · .PDF · 951 KBPhoto 11 - Fuel Tank Selector HandleItem 23 · .PDF · 2.7 MBPhoto 12 - Instrument PanelItem 24 · .PDF · 781 KBPhoto 13 - Left Wing Fuel Tank Bladder, Removed from WingItem 25 · .PDF · 1.0 MBPhoto 14 - Engine Oil DipstickItem 26 · .PDF · 873 KBPhoto 15 - Engine Mounted in Test CellItem 27 · .PDF · 746 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.