# NTSB ERA16LA062: Beech D35, N2991B, Vine Grove, KY, December 4, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 4, 2015, 16:15 local (21:15 UTC) - Place: Vine Grove, KY - Coordinates: 37.815834, -85.964721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.8158&lon=-85.9647&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 15, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92407 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA062 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92407/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92407 - Page: https://openairdocs.org/ntsb/ERA16LA062 ## 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 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: [Beech D35, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151510), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech D35, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151510), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech D35, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151510), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/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: [Beech D35, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=1151510), [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. - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech D35, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151510), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech D35, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151510), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech D35, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151510), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N2991B-2016-02-22), registration cancelled 2016-02-22, S/N D-3629, built 1953 (OpenAirDocs) - Reported make and model: BEECH D35 (NO SERIES) - Registry model: [Beech D35](https://openairdocs.org/model/beech-d35) (registry code 1151510) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-3629 - Year built: 1953 - Airframe hours: 6830.48 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; 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 ## 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 20151204021059A](https://openairdocs.org/incident/20151204021059A), Dec 4, 2015: Beech D35, Vine Grove, KY, Substantial damage. On Friday 12/04/2015 at 16:15 local, N2991B departed Vine Grove KY (70KY). On climb out, the engine lost power and impacted terrain. The pilot stated to FAA… ## Docket (3 files) The files NTSB released with the investigation on October 24, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92407. 3.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467674&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Excerpt form POH-fuel limitations (item 2, .PDF, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467675&FileExtension=.PDF&FileName=Excerpt%20form%20POH-fuel%20limitations-Master.PDF - Photo Array (item 3, .PDF, 954 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467677&FileExtension=.PDF&FileName=Photo%20Array-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.