# NTSB ERA14LA336: Beech C24R, N6222Q, Titusville, FL, July 10, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 10, 2014, 11:50 local (15:50 UTC) - Place: Titusville, FL - Coordinates: 26.609167, -80.824722 - Nearby events: https://openairdocs.org/map.md?lat=26.6092&lon=-80.8247&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report April 27, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, FAA/FSDO - NTSB case key (mKey): 89640 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA336 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89640/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89640 - Page: https://openairdocs.org/ntsb/ERA14LA336 ## Probable cause The pilot's failure to secure the fuel strainer drain during the preflight inspection, which resulted in a total loss of engine power due to fuel exhaustion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1151254), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151254), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=1151254), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md) - [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=1151254), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Beech C24R, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=1151254), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech C24R, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151254), [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 C24R, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151254), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C24R, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151254), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, while conducting a preflight inspection, he looked inside the wing fuel tanks and estimated that there was about 27 gallons of fuel. He then departed on a local flight to test the avionics and autopilot system. While returning to the airport after an approximate 1-hour flight, the engine experienced a total loss of power, and the pilot attempted a forced landing on the roof of a building. The airplane crashed through the roof, which resulted in substantial damage to the wings, fuselage, and flight control surfaces. No visible fuel or fuel odor was noted at the accident site. A postaccident examination of the airplane revealed that both fuel tanks had been breached and were void of fuel. The fuel strainer sump, which sits forward of the firewall below the fuselage, was found in the open-and-locked position. When the strainer valve's tangs were pushed up and rotated counter-clockwise, the sump remained in the open-and-locked position. The sump sprang back to the closed position when the tangs were pushed up and released. Postaccident fuel consumption calculations and fuel strainer drain testing revealed that the airplane would have burned through and lost about 28 gallons of fuel during the approximate 1-hour flight with the strainer drain not properly secured. ## Factual narrative On July 10, 2014, about 1150 eastern daylight time, a Beechcraft C24R, N6222Q, was substantially damaged during a forced landing near Titusville, Florida. The commercial pilot and the passenger received minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed Space Coast Regional Airport (TIX), Titusville, Florida at 1042. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to written statements by the pilot and passenger, the purpose of the flight was to test some recently serviced avionics and the auto pilot system. After an uneventful departure, the pilot changed the fuel selector from the left tank to the right tank and flew north along the coast for about 30 minutes. The pilot then made a 180-degree turn to the south and switched the fuel selector to the left tank. About that time, the pilot momentarily detected an odor of fuel. His passenger did not smell any fuel, and the pilot reported no abnormal engine indications. After about 30 additional minutes of flight, the pilot descended the airplane to an altitude about 1,200 feet above ground level, and the engine subsequently experienced a total loss of power. The pilot manipulated the fuel selector and activated the fuel boost pump, but the engine did not restart. He attempted a forced landing on the roof of an automotive supply store, but the airplane crashed through the roof and came to rest upright inside the building. The pilot added that prior to the flight, he estimated the fuel quantity by visually estimating the distance between the top of the fuel and each wing tank tab, which corresponded to a departure with 27 gallons of fuel onboard and he flew for about 45 minutes on the left wing tank and 23 minutes on the right wing tank before the engine lost all power. Postaccident examination by a Federal Aviation Administration (FAA) inspector revealed that the airplane had sustained substantial damage to the wings and empennage. There was also a fuel sump strainer valve on the underside of the fuselage that was observed in the "locked" open position. The strainer valve was equipped with two "tangs" that extended through a track on the side of the valve. When the tangs were pushed up the valve opened, which allowed fuel to flow out. When the tangs were release a spring pushed the valve to the closed position. The valve could be "locked" in an open position by pushing the tangs up and then rotating the valve counter clockwise until the tangs reached the end of the tracks. When the tangs on the sump valve were pushed in and release on the accident airplane, the valve would spring back to the closed and locked position. The valve remained in the open and locked position when pushed up and turned counter clockwise. According to the FAA inspector, first responders reported that the fuel tanks were breached and there was no evidence of fuel at the accident site. Theinspector also stated the sump strainer valve was located several inches below the fuselage and, as a result, it was possible that leaking fuel would fall below and not contact or stain the fuselage. The airplane was examined and the engine test-run at a secure facility by a FAA inspector, who was assisted by a representative of the airframe manufacturer. The engine was test run for several minutes with the throttle in the idle setting and ran smoothly and continuously, but was shut down due to the condition of the engine mounts and induction lines. The examination revealed that the fuel sender, fuel tank gauges and fuel boost pump functioned normally and no leaks were discovered in any of the fuel lines. The airplane was manufactured in 1982 and was equipped with an IO-360-A1B6, 200 horsepower, reciprocating engine. The airplane's most recent annual inspection was completed on March 10, 2014 at a total airframe time of 2,835 hours. The engine had accumulated 908 hours of operation since its most recent overhaul. According to the manufacturer's pilot's operating handbook, at a cruise altitude of 5,000 to 6,000 feet, under standard atmospheric conditions, and at a maximum cruise power, the airplane's estimated fuel consumption was approximately 10.2 gallons per hour. During subsequent testing, a similar airplane was used to check the flow rate through the strainer drain. Approximately 2 quarts were drained through the strainer drain in 2.3 minutes without the engine running. Performance calculations indicated that the engine would have burned about 7.5 gallons from the left wing tank and 3.8 gallons from the right wing tank. Between the airplane's fuel burn and the results from the strainer drain testing, the airplane would have vacated a total of about 28 gallons of fuel in flight. ## Aircraft - Registration: [N6222Q](https://openairdocs.org/deregistered/N6222Q-2018-03-15), registration cancelled 2018-03-15, S/N MC-771, built 1982 (OpenAirDocs) - Reported make and model: BEECH C24R - Registry model: [Beech C24R](https://openairdocs.org/model/beech-c24r) (registry code 1151254) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MC-771 - Year built: 1982 - Airframe hours: 2835 - Engines: Lycoming IO-360-A1B6 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Southeast Aviation Services, Inc. - Registered owner: Southeast Aviation Services, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 10, 2014, 10 hours before - Departed: TIX, Titusville, FL - Destination: TIX, Titusville, FL - Airport: X21, Arthur Dunn Airpark, runway 33, 2,961 × 70 ft, asphalt - Equipment: Electronic multifunction display, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: minor; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review May 2, 2014; seat: left; restraint: 3-point; flight hours: 5,500 total, 12 in this make and model, 4,500 as pilot in command, 6.3 in the last 90 days, 2.6 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 8 knots - Visibility: 7 statute miles - Temperature: 84 °F, dew point 73 °F - Altimeter: 30.14 inHg - Observed at: TIX, 6 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 20140710013659A](https://openairdocs.org/incident/20140710013659A), Jul 10, 2014: Beech C24R, Titusville, FL, Destroyed. On 07/10/14 the pilot[privacy data omitted] flew N6222Q to functionally check out the avionics equipment he recently had repaired, his intention was to depart… ## Docket (16 files) The files NTSB released with the investigation on March 24, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89640. 22.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423697&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot and Passenger Statements (item 2, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423698&FileExtension=.PDF&FileName=Pilot%20and%20Passenger%20Statements-Redacted.PDF - Correspondence with FAA (item 3, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423699&FileExtension=.PDF&FileName=Correspondence%20with%20FAA-Redacted.PDF - Correspondence with Airframe Manufacturer (item 4, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423701&FileExtension=.PDF&FileName=Correspondence%20with%20Airframe%20Manufacturer-Redacted.PDF - Air Traffic Control Statements (item 5, .PDF, 467 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423700&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Statements-Redacted.PDF - Weather Report and Record (item 6, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423702&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - Beechcraft C24R Fuel System Description (item 7, .PDF, 632 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423704&FileExtension=.PDF&FileName=Beechcraft%20C24R%20Fuel%20System%20Description-Master.PDF - Strainer Drain Valve Information (item 8, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423705&FileExtension=.PDF&FileName=Strainer%20Drain%20Valve%20Information-Master.PDF - Evidence Control Form –Strainer Sump (item 9, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423707&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20%E2%80%93Strainer%20Sump-Master.PDF - Fuel Performance Calculations (item 10, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423708&FileExtension=.PDF&FileName=Fuel%20Performance%20Calculations-Master.PDF - Party Form (item 11, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423714&FileExtension=.PDF&FileName=Party%20Form-Redacted.PDF - Release of Wreckage (item 12, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423706&FileExtension=.PDF&FileName=Release%20of%20Wreckage-Redacted.PDF - Photo 1 - Airplane at Accident Site (Photo Courtesy of FAA) (item 13, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423709&FileExtension=.PDF&FileName=Photo%201%20-%20Airplane%20at%20Accident%20Site%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Airplane at Recovery Facility (Photo Courtesy of FAA) (item 14, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423710&FileExtension=.PDF&FileName=Photo%202%20-%20Airplane%20at%20Recovery%20Facility%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 - Fuel Strainer Sump Valve (item 15, .PDF, 6.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423711&FileExtension=.PDF&FileName=Photo%203%20-%20Fuel%20Strainer%20Sump%20Valve-Master.PDF - Photo 4 - Fuel Strainer (item 16, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40423712&FileExtension=.PDF&FileName=Photo%204%20-%20Fuel%20Strainer-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.