ERA17LA070

NTSB accident investigation · Beech A36 · Ormond Beach, FL · December 17, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
December 17, 2016, 16:07 local (21:07 UTC)
Place
Ormond Beach, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N410BCBeech A36
Defining event
Maneuvering: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed · report April 4, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20161217021209A
Case key
94513

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

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Probable cause

The pilot's impairment by alcohol before and during the flight, which led to his improper fuel management and resulted in fuel exhaustion and a subsequent loss of engine power.

Findings · 5

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 A36: 22 casesAll aircraft: 1,695 casesProbable cause
Impairment/incapacitation: alcoholPersonnel issues › Physical · PilotBeech A36: 3 casesAll aircraft: 87 casesProbable cause
Runway/land/takeoff/taxi surface: soft surfaceEnvironmental issues › Physical environment · Contributed to outcomeBeech A36: 2 casesAll aircraft: 264 cases

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 he was returning to his home airport and was practicing maneuvers at 1,200 ft. The left fuel tank ran dry, and the engine experienced a total loss of power. He stated that his normal procedure was to exhaust the fuel in one tank before switching to the other tank. He attempted to restart the engine after switching to the right tank, which, he stated, held 40 gallons of fuel. The engine would not restart, so he conducted a forced landing in a field. After touchdown, the landing gear collapsed, and the airplane nosed down into the ground. Examination of the fuel system revealed that the left wing was substantially damaged and that the left wing fuel tank was breached. The right wing had minimal damage, and the right wing fuel tank was undamaged. No fuel was found in either fuel tank, and the wing tank selector handle was found in the "off" position. Examination of the engine and airframe did not reveal any evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Blood was drawn from the pilot about 1 hour after the accident, and it tested positive for 0.177 gm/dl of alcohol. At the time of the accident, the pilot's alcohol level was likely at or above 0.185 gm/dl, which is considered impairing. The pilot's impairment by alcohol before and during the flight likely led to his improper fuel mismanagement and the subsequent loss of engine power.

Factual narrative

On December 17, 2016, at 1607 eastern standard time, a Beech A36, N410BC, was substantially damaged during a forced landing at Ormond Beach, Florida. The private pilot was seriously injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Day, visual meteorological conditions prevailed at the time, and no flight plan was filed. The flight originated at DeLand Municipal Airport (DED), DeLand, Florida, about 1430 and was destined for Mid Florida Air Service Airport (X55), Eustis, Florida.The pilot reported in a telephone interview that he was returning to his home airport and was practicing maneuvers at 1,200 feet. The left fuel tank ran dry, and the engine lost all power. He stated that his normal procedure was to exhaust the fuel in one tank before switching to the other. He attempted a restart after switching to the right tank, which, he stated, held 40 gallons of fuel. The engine would not restart, so he performed a forced landing in a field. After touchdown, the landing gear collapsed and the airplane nosed down into the ground. The pilot did not complete and return the NTSB Form 6120.1, Pilot/Operator Aircraft Accident Report, as requested on multiple occasions by the NTSB investigator-in-charge. The pilot also did not provide the aircraft maintenance records when requested by the Federal Aviation Administration (FAA) inspector. The details of the latest annual inspection of the aircraft and engine were not available. The wreckage was recovered from the accident site on December 22, 2017. According to the salvage operator, the left wing was substantially damaged and the left wing fuel tank was breached. The fuselage sustained structural damage. The right wing had minimal damage and the right wing fuel tank was undamaged. No fuel was found in either wing fuel tank. The wing tank selector handle was found in the "OFF" position. The engine was examined on April 6, 2017. The engine was rotated by hand at the propeller, and compression and suction were observed on all six cylinders. All gears were observed rotating at the accessory (rear) section of the engine. The top spark plugs were removed; their electrodes were intact and were light grey in color. The engine-driven fuel pump was removed; the drive coupling was intact and the pump rotated smoothly. The engine-driven fuel pump was forwarded to the manufacturer's facility for further examination. The fuel pump displayed impact damage signatures; one of the fuel line AN fittings was fractured. The fuel pump drive shaft was noted to have remained intact and the fuel pump drive shaft was capable of normal rotation. The fractured AN fitting was removed and a serviceable fitting was installed. The fuel pump was placed on a production bench for testing; the fuel pump operated normally. There were no anomalies noted. According to the FAA medical file, the pilot was first medically certified to fly in1978. In 2004, he reported a diagnosis of hypertension and treatment with medication. In February, 2008, he was admitted to hospital for several weeks with multiple complex complications of chronic alcoholism, then was admitted for alcohol rehabilitation, and he reported that to the FAA. After obtaining more information including a neurology evaluation following an alcohol withdrawal seizure, and a psychiatric evaluation, the FAA eventually granted him a special issuance third class medical certificate in 2009, which was dependent on him being evaluated and undergoing periodic testing for alcohol. At the time of his last aviation medical examination, dated August 30, 2011, the pilot reported 1,650 total flight hours. In September, 2011, he tested positive for alcohol and the FAA withdrew his medical certificate in November, 2011. The pilot was taken emergently to the hospital by helicopter following the accident. Blood drawn at 1709 tested positive for 0.177 gm/dl of alcohol. No other toxicology testing was performed. Ethanol is the intoxicant commonly found in beer, wine, and liquor. It acts as a central nervous system depressant. After ingestion, at low doses, it impairs judgment, psychomotor functioning, and vigilance; at higher doses it can cause coma and death. The effects of ethanol on aviators are generally well understood; it significantly impairs pilots' performance, even at very low levels. CFR Part 91.17 (a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. Unlike many other substances, ethanol is eliminated from the body at a fairly constant rate. The rate varies with the regularity of drinking and whether or not the individual has recently eaten, but ranges from 0.010 gm/dl/hr in infrequent drinkers with an empty stomach to as high as 0.035 gm/dl/hr in heavy drinkers who have eaten. As a result, the minimum and maximum levels of ethanol can be back-calculated with some assurance of accuracy. Thus, at the time of the accident, the pilot's alcohol level was likely at or above 0.185 gm/dl.

Aircraft

Registration
N410BC
Reported as
Beech A36 (UNDESIGNAT)
Category
Airplane
Serial number
E-1606
Built
1979
Engine
Continental IO-520 Series, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
DED · Deland, FL
Destination
X55 · Eustis, FL
Equipment
Unknown

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
57
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
1,500 total · 1,000 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 10 knots
Visibility
10 statute miles
Temperature
82 °F, dew point 63 °F
Altimeter
30.10 inHg
Observed at
OMN, 8 nm away

Docket · 13

The files NTSB released with the investigation on December 10, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 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.