# NTSB ERA17LA070: Beech A36, N410BC, Ormond Beach, FL, December 17, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 17, 2016, 16:07 local (21:07 UTC) - Place: Ormond Beach, FL - Coordinates: 29.266666, -81.254722 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.2667&lon=-81.2547&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 4, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 94513 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA070 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94513/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94513 - Page: https://openairdocs.org/ntsb/ERA17LA070 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech A36, 22 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151604), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Impairment/incapacitation: alcohol](https://openairdocs.org/ntsb-findings/02012015): Personnel issues › Physical · Pilot (probable cause); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02012015/cases.md?model=1151604), [All aircraft, 87 cases](https://openairdocs.org/ntsb-findings/02012015/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot; cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Runway/land/takeoff/taxi surface: soft surface](https://openairdocs.org/ntsb-findings/03023020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md?model=1151604), [All aircraft, 264 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot; cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=1151604), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=1151604), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Maneuvering: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Beech A36, 7 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=1151604), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Beech A36, 12 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=1151604), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=1151604), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N410BC-2019-09-06), registration cancelled 2019-09-06, S/N E-1606, built 1979 (OpenAirDocs) - Reported make and model: BEECH A36 (UNDESIGNAT) - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-1606 - Year built: 1979 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: serious; 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 ## 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 20161217021209A](https://openairdocs.org/incident/20161217021209A), Dec 17, 2016: Beech A36, Ormond Beach, FL, Substantial damage. An aircraft had crashed in a wooden area next to a hunters club in Ormond Beach, Florida. The aircraft was N-410BC, a Beech A36, serial # E-1606, registered to… ## Docket (13 files) The files NTSB released with the investigation on December 10, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94513. 4.7 MB in all. - FAA Inspector Statement (item 1, .PDF, 715 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469167&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - FAA Record of Telephone Call 1 - Fish (item 2, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469168&FileExtension=.PDF&FileName=FAA%20Record%20of%20Telephone%20Call%201%20-%20Fish-Master.PDF - FAA Record of Telephone Call 2 - Fish (item 3, .PDF, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469169&FileExtension=.PDF&FileName=FAA%20Record%20of%20Telephone%20Call%202%20-%20Fish-Master.PDF - Memorandum for Record – Telephone Interview, Pilot (item 4, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469170&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Pilot-Master.PDF - Flagler County FL Case Reports (item 5, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469171&FileExtension=.PDF&FileName=Flagler%20County%20FL%20Case%20Reports%20-Master.PDF - Memorandum for Record – Telephone Interview, Recovery Personnel (item 6, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469172&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Recovery%20Personnel-Master.PDF - Memorandum for Record – Requests for NTSB Form 6120.1 (item 7, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469173&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Requests%20for%20NTSB%20Form%206120.1-Master.PDF - Photo Array (item 8, .PDF, 373 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469174&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - NTSB Engine Examination Report (item 9, .PDF, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469175&FileExtension=.PDF&FileName=NTSB%20Engine%20Examination%20Report-Master.PDF - CMI Fuel Pump Examination Report (item 10, .PDF, 572 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469176&FileExtension=.PDF&FileName=CMI%20Fuel%20Pump%20Examination%20Report-Master.PDF - Medical Factual Report (item 11, .PDF, 506 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469177&FileExtension=.PDF&FileName=Medical%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 514 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469179&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Evidence Control Form (item 13, .PDF, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469180&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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.