# NTSB ERA18TA203: Beech C90, N717X, Lecanto, FL, July 26, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Final report - Date: July 26, 2018, 17:55 local (21:55 UTC) - Place: Lecanto, FL - Coordinates: 28.878889, -82.49472 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.8789&lon=-82.4947&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 97910 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18TA203 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97910/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97910 - Page: https://openairdocs.org/ntsb/ERA18TA203 ## Probable cause The pilot's failure to turn on the fuel transfer pumps in accordance with the published checklists, which resulted in a dual loss of engine power due to fuel starvation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Beech C90, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=1152913), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech C90, 3 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=1152913), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech C90, 2 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1152913), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech C90, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=1152913), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech C90, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1152913), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech C90, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1152913), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C90, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152913), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The commercial pilot reported that, before a short, cross-country, personal flight, he purchased 40 gallons of fuel; 20 gallons of fuel were added to each wing tank. The pilot estimated that, at the time of departure, the airplane had a total fuel load of about 130 gallons with 65 gallons in each wing tank. About 10 minutes after departure, the left engine's power surged. The pilot attempted to divert to a nearby airport, but the left engine lost all power during the approach, followed by the right engine losing all power. The pilot was not sure if the airplane could glide to the runway, so he chose to perform a forced landing to a field. During the landing roll, the right wing impacted a tree and was substantially damaged. The airplane was equipped with six fuel tanks; two interconnected tanks in each wing and one tank in each engine's nacelle. On each side of the airplane, fuel flowed from the respective wing tanks to the nacelle tank and then to the engine. Fuel would gravity feed from the wing tanks to the nacelle tanks; however, gravity feed did not work once each wing tank was depleted to about 28 gallons or below. At that point, the fuel transfer pumps (one for each wing/nacelle) must be on to keep the fuel moving to the nacelle tanks and ultimately the engines. Examination of the wreckage revealed that the fuel transfer pumps were in the "off" position. No fuel was found in the nacelle tanks, and about 30 gallons of fuel were found in each wing tank. When the battery and fuel transfer pumps were turned on, fuel began to flow from each wing tank to its respective nacelle tank. Turning on the fuel transfer pumps is an After Starting and Taxi checklist item; therefore, it is unlikely that the pilot followed the checklist and that he forgot to turn the fuel transfer pumps on, which resulted in fuel starvation to both engines and their subsequent loss of power. ## Factual narrative On July 26, 2018, about 1755 eastern daylight time, a Beech C90, N717X, was substantially damaged during a forced landing to a field, following a total loss of power on both engines near Lecanto, Florida. The commercial pilot was not injured. The airplane was registered to and operated by LILSA KA LLC as a personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Williston Municipal Airport (X60), Williston, Florida. The flight departed Brooksville-Tampa Bay Regional Airport (BKV), Brooksville, Florida, about 1740.The pilot reported that earlier during the day of the accident, he flew uneventfully from X60 to BKV to have some maintenance work performed on the brakes. While at BKV, he purchased 40 gallons of fuel, 20 gallons were added to each wing. The pilot estimated that at the time of departure, the airplane had a total fuel load of 870 lbs. (about 130 gallons total, 65 gallons per side). The pilot then waited for some convective weather to subside and departed on a return flight to X60. Due to some scattered thunderstorms remaining in the area, the pilot flew west and then followed the coast north. While flying over Crystal River Airport (CGC), Crystal River, Florida, the engine power surged on the left engine. The pilot diverted toward CGC and was flying a wide right downwind traffic pattern for runway 27 while trying to troubleshoot the engine anomaly. As he turned the airplane onto the right base leg of the traffic pattern, the left engine lost all power; then when he subsequently turned onto the final approach leg of the traffic pattern, the right engine lost all power. The pilot was not sure if the airplane would glide to the runway and elected to perform a forced landing to a field. During the landing roll, the right wing impacted a tree. Review of an airplane flight manual revealed that the airplane was equipped with six fuel tanks; two interconnected tanks in each wing and one tank in each engine nacelle. Fuel flowed from the respective wing tanks, to the nacelle tank, to the engine. Fuel would gravity feed from the wing tanks to nacelle tank; however, the gravity feed does not work once the wing tanks are depleted to about 28 gallons (total per each wing) or below. At that point, the fuel transfer pumps (one for each wing/nacelle) must be on to keep fuel moving to the nacelle tanks and ultimately the engines. Review of the after starting and taxi checklist revealed instructions to turn the fuel transfer pumps on. Examination of the wreckage by a Federal Aviation Administration inspector revealed that the airplane came to rest upright in a field about 4 miles east of CGC. The right wing sustained substantial damage and the rest of the airplane remained undamaged. A local mechanic inspected the wreckage at the scene for the purposes of providing a repair estimate. During the inspection, the mechanicnoted that the fuel transfer pumps were in the off position. He also observed no fuel in the nacelle tanks and about 30 gallons of fuel in each wing. The mechanic then turned on the battery and fuel transfer pumps. At that point, fuel began to flow from each wing tank to the respective nacelle tank. ## Aircraft - Registration: [N717X](https://openairdocs.org/aircraft/N717X), registered now, S/N LJ-581, built 1973 (OpenAirDocs) - Reported make and model: Beech C90 (UNDESIGNAT) - Registry model: [Beech C90](https://openairdocs.org/model/beech-c90) (registry code 1152913) (OpenAirDocs) - Registry engine: [Walter M601E-11S](https://openairdocs.org/engine/walter-m601e-11s) (registry code 64007, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: LJ-581 - Year built: 1973 - Airframe hours: 8287 - Engines: Walter M601E-115 751 horsepower turbo prop; Walter M601E-115 751 horsepower turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Lilsa Ka Llc - Registered owner: Lilsa Ka Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 11, 2017, 172 hours before - Departed: BKV, Brooksville, FL - Destination: X60, Williston, FL - Equipment: Electronic primary flight display, Onboard weather, Stall warning system, Auto-pilot, Electronic multifunction display, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review January 20, 2016; seat: left; restraint: 3-point; flight hours: 1,620 total, 172 in this make and model, 1,555 as pilot in command, 55 in the last 90 days, 13 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 77 °F - Altimeter: 29.97 inHg - Observed at: CGC, 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 20180726018059A](https://openairdocs.org/incident/20180726018059A), Jul 26, 2018: Beech C90, Lecanto, FL, Substantial damage. Pilot stated he put 40 gallons of fuel on board the aircraft and departed brooksville, FL (bkv) to williston, Florida (X60). Stated the left engine sputtered… ## Docket (5 files) The files NTSB released with the investigation on February 19, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97910. 2.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 861 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470451&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summary (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470452&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Excerpts from AFM (item 3, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470453&FileExtension=.PDF&FileName=Excerpts%20from%20AFM-Master.PDF - Photo Array (item 4, .PDF, 2 photos, 975 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470454&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Weather Report (item 5, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470455&FileExtension=.PDF&FileName=Weather%20Report-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.