# NTSB ERA19LA136: Beech 95B55, N323MT, Clewiston, FL, March 25, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: March 25, 2019, 12:10 local (16:10 UTC) - Place: Clewiston, FL - Coordinates: 26.32361, -80.943336 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.3236&lon=-80.9433&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor, 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Continental Aerospace Technologies, FAA-FSDO - NTSB case key (mKey): 99170 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA136 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99170/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99170 - Page: https://openairdocs.org/ntsb/ERA19LA136 ## Probable cause The pilot's mismanagement of the available fuel, which resulted in a total loss of engine power due to fuel starvation. Contributing to the accident was the pilot’s failure to perform the appropriate emergency checklists following the loss of engine power. ## 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 95-B55 (T42A), 13 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1152706), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech 95-B55 (T42A), 15 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1152706), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/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 95-B55 (T42A), 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1152706), [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: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Beech 95-B55 (T42A), 2 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=1152706), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech 95-B55 (T42A), 7 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1152706), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech 95-B55 (T42A), 7 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1152706), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [After landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 95-B55 (T42A), 22 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152706), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed on a cross-country flight with the fuel selectors set to the main fuel tanks. Upon reaching a cruise altitude of 6,000 ft, the left engine lost total power. The pilot tried to restart the engine but was unsuccessful. Shortly thereafter, the right engine lost total power. The pilot reported that he did not use the emergency checklist or switch the fuel selector to another tank, as he was too busy trying to restart the engines. The pilot conducted a forced landing to a field, during which the airplane impacted an irrigation ditch, resulting in substantial damage. The fuel selector was found set to the main fuel tanks, which were devoid of fuel. However, measurable fuel was found in the remaining two auxiliary tanks. Examination of the engine and fuel system revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. Given the available evidence, it is likely that the loss of engine power was due to the pilot's mismanagement of the available fuel, which resulted in fuel starvation. It is also likely that, had the pilot completed the emergency checklist for a loss of engine power/engine restart, fuel flow and engine power would have been restored. ## Factual narrative On March 25, 2019, about 1210 eastern daylight time, a Beech 95B55, N323MT, was substantially damaged when it was involved in an accident near Clewiston, Florida. The pilot sustained minor injuries, one passenger was seriously injured, and a second passenger was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he ordered 30 gallons (15 gallons per side) of fuel to be placed in the airplane's auxiliary fuel tanks the night before the accident. On the day of the accident, the pilot performed a preflight inspection of the airplane before starting the engines and taxiing to the active runway, but he did not visually verify that there was fuel in the tanks. The pilot took off with the fuel selector positioned to the main fuel tanks and climbed to 6,000 ft mean sea level (msl) for the estimated 1 hour and 10-minute flight. Shortly after leveling off, the left engine lost total power. He tried to restart the engine, but was unsuccessful, and he contacted air traffic control to request vectors to the nearest airport. Within 5 minutes of the left engine losing power, the right engine lost power. He tried restarting the right engine multiple times while feathering and securing the left engine. The pilot stated he could see the airport ahead, but did not feel he had enough altitude to glide to the runway and selected a field for a forced landing. During landing, the airplane impacted an irrigation ditch, substantially damaging the right wing and fuselage. Throughout the flight, the pilot did not attempt to move the fuel selectors from the main fuel tank position. In addition, he stated he did not use a checklist while performing the engine shutdown, since he was working to secure the engines. A Federal Aviation Administration inspector examined the airplane and found that both main fuel tanks were absent of fuel. Both auxiliary fuel tanks contained fuel; however, the specific quantity was not determined. In addition, both fuel selector valves were positioned to the main fuel tanks. A fuel receipt confirmed that the auxiliary tanks had each been serviced with 15 gallons of fuel on the day before the accident. The amount of fuel in the airplane’s main fuel tanks at the time of takeoff could not be determined. An examination of both engines revealed no anomalies that would have precluded normal operation. ## Aircraft - Registration: [N323MT](https://openairdocs.org/deregistered/N323MT-2021-06-10), registration cancelled 2021-06-10, S/N TC-1256 (OpenAirDocs) - Reported make and model: Beech 95B55 - Registry model: [Beech 95-B55 (T42A)](https://openairdocs.org/model/beech-95-b55-t42a) (registry code 1152706) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TC-1256 - Year built: 1969 - Airframe hours: 2400 - Engines: Continental IO-470-L-19 260 horsepower reciprocating; Continental IO-470-L-19 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 1, 2018 - Departed: FXE, Fort Lauderdale, FL - Destination: PIE, St Petersburg-Clearwater, FL - Flight plan: IFR - Equipment: Electronic flight bag or handheld device, Auto-pilot, Stall warning system, Onboard weather, Electronic primary flight display, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: minor; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review July 27, 2018; seat: left; restraint: lap only; flight hours: 905 total, 40 in this make and model, 615 as pilot in command, 67 in the last 90 days, 22 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 61 °F - Altimeter: 30.12 inHg - Observed at: APF, 46 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 20190325001989A](https://openairdocs.org/incident/20190325001989A), Mar 25, 2019: Beech 95-B55 (T42A), Clewiston, FL, Substantial damage. Aircraft departed fort lauderdale executive airport at approx. 11:00AM EDT. Pilot received fuel for auxiliary tanks before departure, but not for main tanks.… ## Docket (10 files) The files NTSB released with the investigation on November 3, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99170. 33.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 9.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9506861&FileExtension=pdf&FileName=NTSB%206120_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9506870&FileExtension=pdf&FileName=Memorandum%20for%20Record-Pilot%20statement_Redacted-Rel.pdf - FAA inspector's statement (item 3, PDF, 2 pages, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9507159&FileExtension=pdf&FileName=FAA%20Inspector%27s%20Statement-%20N323MT_Redacted-Rel.pdf - Pilot operating handbook - engine restart procedure (item 4, PDF, 1 page, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9506976&FileExtension=pdf&FileName=Engine%20air%20start%20procedures-Rel.pdf - Pilot operating handbook - fuel system discription (item 5, PDF, 5 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9508073&FileExtension=pdf&FileName=POH%20-%20Fuel%20System%20Discription-Rel.pdf - Fuel receipt (item 6, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9507168&FileExtension=pdf&FileName=N323MT%20Fuel%20receipt-Rel.pdf - Photo array (item 7, PDF, 3 pages, 5 photos, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9507358&FileExtension=pdf&FileName=Photo%20Array%20ERA19LA136-Rel.pdf - Left engine examination report (item 8, PDF, 30 pages, 96 photos, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9507687&FileExtension=pdf&FileName=18-373%20N323MT%20Left%20Engine%20Examination%20Report_Redacted-Rel.pdf - Right engine examination report (item 9, PDF, 32 pages, 98 photos, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9508632&FileExtension=pdf&FileName=18-373%20N323MT%20Right%20Engine%20Examination%20Report_Redacted-Rel.pdf - Party form - Continental aerospace technologies (item 10, PDF, 1 page, 586 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9509770&FileExtension=pdf&FileName=KG%20Party%20Form%20ERA19LA136%20Redacted-Rel.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.