ERA16LA062

NTSB accident investigation · Beech D35 · Vine Grove, KY · December 4, 2015

Accident · No injuriesLimited investigationFinal report
Date
December 4, 2015, 16:15 local (21:15 UTC)
Place
Vine Grove, KY
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2991BBeech D35
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report November 15, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20151204021059A
Case key
92407

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s failure to ensure that the fuel selector was properly positioned before takeoff, which resulted in the subsequent total loss of engine power due to fuel starvation.

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech D35: 3 casesAll aircraft: 1,391 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotBeech D35: 1 caseAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech D35: 1 caseAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotBeech D35: 1 caseAll aircraft: 191 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 private pilot reported that, when he departed for the personal flight, there were 15 gallons of fuel in each of the wing fuel tanks. During the initial climb, the airplane experienced a total loss of engine power. Subsequently, the pilot performed an emergency off-airport landing. During the landing, the airplane sustained substantial damage to the fuselage, wings, and firewall. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical anomalies that would have precluded normal operation. The right fuel tank was breached, and an undetermined amount of fuel was noted in the left fuel tank. About 1 gallon of fuel was drained from the auxiliary fuel tank drain valve. Although the pilot stated that he did not remember which fuel tank he had selected before takeoff, given the airplane's fuel state that he reported before takeoff and the fuel observed in the airplane postaccident, it is likely that the pilot mistakenly departed with the fuel selector positioned to the auxiliary fuel tank, which according to the manufacturer, was to be used only during level flight and not for takeoff or landing and that this resulted in the subsequent total loss of engine power due to fuel starvation.

Factual narrative

On December 4, 2015, at 1615 eastern standard time, a Beechcraft D35, N2991B, was substantially damaged during a forced landing after takeoff from the Vine Grove Airport (70KY), Vine Grove, Kentucky. The private pilot was not injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed.The pilot reported that his intention was to conduct some "pattern work." He conducted a preflight inspection of the airplane; visually checked the fuel in the left and right fuel tanks and estimated that they each contained 15 gallons. The airplane was equipped with a 20-gallon auxiliary fuel tank but the pilot reported that its fuel quantity could not be checked visually. The pilot started the engine, taxied to the run-up area, and performed the before takeoff checklist items, with no anomalies noted. He then taxied to the active runway and configured the airplane for takeoff. During the climbout, about 150 feet above ground level, the engine "quit." He did not have enough altitude to return to the airport, or time to attempt an engine restart or make any radio calls. He subsequently performed an emergency off-airport landing to a road. Examination of the airplane by a Federal Aviation Administration inspector revealed that the right wing and firewall were buckled. The left main wing fuel tank had an undetermined amount of fuel. Fuel samples were taken from the left main wing tank and the fuselage auxiliary tank. The samples appeared to be clear with no water or debris noted. The right wing fuel tank was breached and the fuel quick drain valve was jammed. The smell of fuel in and around the airplane was noted. The fuel selector was moved from the off position and back to the auxiliary position, and when the fuel supply line was removed from the carburetor, very little fuel exited. The fuel strainer was removed and a very small amount of fuel came out; it was inspected and found to be free of debris. The auxiliary fuel tank drain valve was removed and about 1 gallon of fuel drained out. A review of the D35 pilot's operating handbook (POH) revealed that the airplane was equipped with a 20-gallon fuel tank in each wing in which 34 gallons are usable. All of the fuel in the auxiliary tank was usable. The top spark plugs were removed and they exhibited normal wear and had light gray deposits in the electrode areas. The crankshaft was rotated by hand, and spark was noted on each spark plug lead. After the examination of the airplane, the pilot reported, "The D-35 has only one fuel gage and two switches used to select the tank indicated. The fuel selector has four positions, left, right, auxiliary and off. You can have the fuel selector on the auxiliary tank and the fuel indicator on a different tank. It is possible that I mistakenly verified the fuel level in the auxiliary tank with the indicator set toone of the main tanks." The pilot stated that he did not remember which fuel tank he had selected before takeoff. According to the limitations section of the D35 POH: "Use auxiliary fuel in level flight only and do not use for takeoff or landing. Use at least 10 gallons from left main tank before use of auxiliary fuel or right main tank."

Aircraft

Registration
N2991B
Reported as
Beech D35 (NO SERIES)
Category
Airplane
Serial number
D-3629
Built
1953
Airframe hours
6,830.48
Engine
Continental E 225-8, 225 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · September 2, 2015 · 18 hours before
Departed
70KY · Vine Grove, KY
Destination
70KY · Vine Grove, KY
Airport
70KY · Vine Grove
Equipment
None

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
53
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
September 4, 2015
Seat
Left
Restraint
Lap only
Flight hours
956 total · 18 in this make and model · 793 as pilot in command · 18 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 6 knots
Visibility
4 statute miles
Lowest ceiling
5,500 ft overcast
Temperature
59 °F, dew point 57 °F
Altimeter
30.00 inHg
Observed at
FTK, 4 nm away

Docket · 3

The files NTSB released with the investigation on October 24, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.6 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.