ERA16LA090

NTSB accident investigation · Beech A23 · Kingston, TN · January 16, 2016

Accident · No injuriesLimited investigationFinal report
Date
January 16, 2016, 11:10 local (16:10 UTC)
Place
Kingston, TN
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N3680QBeech A23
Defining event
Approach: Fuel starvation
Weather
Visual (VMC) · Not reported
Status
Completed · report July 16, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20160116005999A
Case key
92580

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 inadequate preflight inspection and fuel planning and his improper in-flight fuel management, which resulted in a total loss of engine power due to fuel starvation.

Findings · 3

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 managementBeech A23A: 3 casesAll aircraft: 1,695 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotBeech A23A: 1 caseAll aircraft: 551 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotBeech A23A: 2 casesAll aircraft: 719 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 performed maintenance on the airplane about 2 weeks before the accident, which included replacing the fuel tank cap O-rings and draining the fuel from the left tank and putting it in the right fuel tank in order to clear debris from the left tank sump valve. Following that work, the pilot believed that the airplane's right fuel tank contained about 28 gallons of fuel and the left fuel tank contained about 1.5 gallons. On the morning of the accident flight, he performed a preflight inspection of the airplane but could not recall if he visually verified the fuel quantity in each tank. After flying around the local area for about an hour with the fuel selector positioned to the right fuel tank, the engine experienced a total loss of power. The pilot performed a forced landing, during which the airplane was substantially damaged. The pilot reported that he kept the fuel selector positioned to the right fuel tank for the entirety of the flight and did not select the left fuel tank after the loss of engine power because he believed it only contained 1.5 gallons of fuel. Examination of the airplane after the accident revealed that the fuel selector was in the right fuel tank position, both fuel tanks were intact, and the right fuel tank was empty. The left tank contained about 7 gallons of fuel. A cursory postaccident examination of the engine found no evidence of any mechanical deficiencies. Given that the pilot used the right fuel tank for the entirety of the flight and that the right fuel tank was found intact and empty after the accident, it is likely that the loss of engine power was the result of fuel starvation.

Factual narrative

On January 16, 2016, at 1110 central standard time, a Beech A23, N3680Q, was substantially damaged during a forced landing near the Riley Creek Airport (12TN), Kingston, Tennessee. The private pilot was not injured. The airplane was privately owned and operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions were reported near the accident site about the time of the accident, and no flight plan was filed. The flight originated from the 12TN at 1015.According to the pilot, two weeks prior to the accident, he replaced the O-rings on the fuel caps and drained all of the fuel out of the left fuel tank in order to clear any debris from the left wing sump valve. He then poured all of the drained fuel into the right wing tank, which brought the right fuel quantity to approximately 28 gallons. He then poured the remaining fuel, which was approximately 1.5 gallons, into the left fuel tank and then sampled the fuel from both tanks for water and other contamination. He then tied down the airplane and placed a tarp over it. On the day of the accident, the pilot returned to the airport and did not recall if he verified the fuel levels prior to his flight. He climbed into the cockpit and conducted a preflight inspection prior to starting the engine. Once the engine was started, he taxied around the ramp area to clean the mud and debris from the tires while warming up the engine. He took off and flew around for approximately 45 minutes before returning to the airport. After landing he taxied around the airport a few more times before departing again. He said that he was flying for about 10 minutes when he decided to return to the airport. As he flew over the airport to see the direction of the wind, the engine stopped. He attempted to troubleshoot the situation and made an unsuccessful attempt to restart the engine but did not move the fuel selector from the right fuel tank for the left fuel tank as he believed it only contained 1 to 1.5 gallons of fuel. The pilot performed an emergency off-field landing. Initial examination of the airplane by a Federal Aviation Administration inspector revealed that the airplane's left wing was broken away from the wing root. The empennage separated from the main cabin and the firewall was buckled. During the examination of the airplane it was noted that the fuel tanks were not breached. Further inspection revealed that the fuel selector was on the right fuel tank. The right fuel tank did not contain any fuel. Examination of the left fuel tank reveal that it had approximately 7 gallons of fuel after draining. A cursory examination was conducted on the engine and valve train continuity was established. The magnetos were checked, and they produced spark to all the spark plugs. Fuel flow was confirmed to the fuel flow divider and fuel injectors. An engine run was attempted but was unsuccessful. During a telephone call with the FAA inspector, the pilotmentioned that he felt that the fuel may have been stolen out of his airplane prior to the accident.

Aircraft

Registration
N3680Q
Reported as
Beech A23 (A)
Category
Airplane
Serial number
M-1052
Built
1967
Airframe hours
1,482
Engine
Cont Motor IO-346 SERIES, 165 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 17, 2015 · 5 hours before
Departed
12TN · Kingston, TN
Destination
12TN · Kingston, TN
Airport
12TN · Riley Creek
Equipment
Angle of attack indicator, Stall warning system

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
51
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
December 5, 2015
Seat
Left
Restraint
3-point
Flight hours
115.1 total · 6.5 in this make and model · 73.9 as pilot in command · 6.5 in the last 90 days · 5.1 in the last 30 days

Weather

Conditions
Visual (VMC) · Not reported
Wind
280° at 3 knots
Visibility
10 statute miles
Lowest ceiling
3,100 ft overcast
Temperature
39 °F, dew point 34 °F
Altimeter
29.89 inHg
Observed at
MMI, 25 nm away

Docket · 5

The files NTSB released with the investigation on April 19, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 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.