# NTSB ERA14FA074: Raytheon G36, N89SN, Panama City, FL, December 18, 2013 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 18, 2013, 07:20 local (13:20 UTC) - Place: Panama City, FL - Coordinates: 30.101943, -85.462219 - Nearby events: https://openairdocs.org/map.md?lat=30.1019&lon=-85.4622&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 7, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Textron Aviation, Continental Motors - NTSB case key (mKey): 88565 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14FA074 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88565/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88565 - Page: https://openairdocs.org/ntsb/ERA14FA074 ## 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 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 level (probable cause); cases with it: [Raytheon G36, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7150061), [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: [Raytheon G36, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7150061), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Equipment/furnishings: emergency equipment](https://openairdocs.org/ntsb-findings/01022560): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Raytheon G36, 1 case](https://openairdocs.org/ntsb-findings/01022560/cases.md?model=7150061), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/01022560/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Raytheon G36, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7150061), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/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 exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Raytheon G36, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=7150061), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Raytheon G36, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7150061), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N89SN-2016-06-02), registration cancelled 2016-06-02, S/N E-3738 (OpenAirDocs) - Reported make and model: RAYTHEON G36 - Registry model: [Raytheon G36](https://openairdocs.org/model/raytheon-g36) (registry code 7150061) (OpenAirDocs) - Category: Airplane - Serial number: E-3738 - Year built: 2006 - Airframe hours: 734 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: fatal; 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 ## 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 20131218024549A](https://openairdocs.org/incident/20131218024549A), Dec 18, 2013: Raytheon Aircraft Company G36, Panama City, FL, Substantial damage, 1 fatal. N89SN BE-36G flight from north palm beach county general aviation airport (F45), west palm beach, Florida to destin-fort walton beach airport (dts), destin,… ## Docket (27 files) The files NTSB released with the investigation on December 17, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88565. 19.8 MB in all. - Transcript of Communications - Tyndall AFB ATC (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420144&FileExtension=.PDF&FileName=Transcript%20of%20Communications%20-%20Tyndall%20AFB%20ATC-Redacted.PDF - Airplane Flight Log Excerpt (item 2, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420145&FileExtension=.PDF&FileName=Airplane%20Flight%20Log%20Excerpt-Master.PDF - Maintenance Logbooks Excerpts (item 3, .PDF, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420146&FileExtension=.PDF&FileName=Maintenance%20Logbooks%20Excerpts-Redacted.PDF - Fuel Records (item 4, .PDF, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420147&FileExtension=.PDF&FileName=Fuel%20Records-Redacted.PDF - Memorandum for Record - Recent Fueling at F45 (item 5, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420148&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Recent%20Fueling%20at%20F45-Master.PDF - Bay County Sheriff Incident Report (item 6, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420149&FileExtension=.PDF&FileName=Bay%20County%20Sheriff%20Incident%20Report-Redacted.PDF - Engine Operational Test Log (item 7, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420150&FileExtension=.PDF&FileName=Engine%20Operational%20Test%20Log-Master.PDF - Flight Path and Accident Site Diagrams (item 8, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420151&FileExtension=.PDF&FileName=Flight%20Path%20and%20Accident%20Site%20Diagrams-Master.PDF - Toxicological Report (item 9, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420152&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Certification of Party Representative (item 10, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420153&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420154&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Evidence Control (item 12, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420155&FileExtension=.PDF&FileName=Evidence%20Control-Redacted.PDF - Photo 1 - Main Wreckage (item 13, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420156&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20Wreckage-Master.PDF - Photo 2 - Empennage (item 14, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420157&FileExtension=.PDF&FileName=Photo%202%20-%20Empennage-Master.PDF - Photo 3 - Fuselage and Empennage (item 15, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420158&FileExtension=.PDF&FileName=Photo%203%20-%20Fuselage%20and%20Empennage-Master.PDF - Photo 4 - Propeller Blade and Engine Compartment (item 16, .PDF, 991 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420159&FileExtension=.PDF&FileName=Photo%204%20-%20Propeller%20Blade%20and%20Engine%20Compartment-Master.PDF - Photo 5 - Engine Cowling (item 17, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420160&FileExtension=.PDF&FileName=Photo%205%20-%20Engine%20Cowling-Master.PDF - Photo 6 - Engine Compartment and Engine, Cowling Opened (item 18, .PDF, 864 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420161&FileExtension=.PDF&FileName=Photo%206%20-%20Engine%20Compartment%20and%20Engine,%20Cowling%20Opened-Master.PDF - Photo 7 - Left Wing Inboard (item 19, .PDF, 852 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420162&FileExtension=.PDF&FileName=Photo%207%20-%20Left%20Wing%20Inboard-Master.PDF - Photo 8 - Forward Fuselage and Left Wing (item 20, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420163&FileExtension=.PDF&FileName=Photo%208%20-%20Forward%20Fuselage%20and%20Left%20Wing-Master.PDF - Photo 9 - Left Wing (item 21, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420164&FileExtension=.PDF&FileName=Photo%209%20-%20Left%20Wing-Master.PDF - Photo 10 - Main Wreckage, Right Side (item 22, .PDF, 951 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420165&FileExtension=.PDF&FileName=Photo%2010%20-%20Main%20Wreckage,%20Right%20Side-Master.PDF - Photo 11 - Fuel Tank Selector Handle (item 23, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420166&FileExtension=.PDF&FileName=Photo%2011%20-%20Fuel%20Tank%20Selector%20Handle-Master.PDF - Photo 12 - Instrument Panel (item 24, .PDF, 781 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420167&FileExtension=.PDF&FileName=Photo%2012%20-%20Instrument%20Panel-Master.PDF - Photo 13 - Left Wing Fuel Tank Bladder, Removed from Wing (item 25, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420168&FileExtension=.PDF&FileName=Photo%2013%20-%20Left%20Wing%20Fuel%20Tank%20Bladder,%20Removed%20from%20Wing-Master.PDF - Photo 14 - Engine Oil Dipstick (item 26, .PDF, 873 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420169&FileExtension=.PDF&FileName=Photo%2014%20-%20Engine%20Oil%20Dipstick-Master.PDF - Photo 15 - Engine Mounted in Test Cell (item 27, .PDF, 746 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420170&FileExtension=.PDF&FileName=Photo%2015%20-%20Engine%20Mounted%20in%20Test%20Cell-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.