ERA19TA276

NTSB accident investigation · Beech 23 · Panama City, FL · September 10, 2019

Accident · No injuriesClass 3Final report
Date
September 10, 2019, 12:20 local (17:20 UTC)
Place
Panama City, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N3555RBeech 23
Defining event
Approach-VFR pattern final: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA
FAA report
20190910014579A
Case key
100294

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

A total loss of engine power due to an obstructed fuel vent, and the flight instructor's failure to ensure that the student did an adequate preflight inspection, which resulted in a forced landing.

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.

Inspection: preflight inspectionPersonnel issues › Task performance · Student/instructed pilotBeech A23: 1 caseAll aircraft: 551 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · Instructor/check pilotBeech A23: 1 caseAll aircraft: 551 casesProbable cause
Object/animal/substance: debris/dirt/foreign objectEnvironmental issues › Physical environment · Awareness of conditionBeech A23: 1 caseAll aircraft: 101 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · Damaged/degradedBeech A23: 1 caseAll aircraft: 141 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · Inadequate inspectionBeech A23: 1 caseAll aircraft: 141 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

After returning from a roundtrip, cross-country flight, the student pilot and flight instructor were conducting airport pattern work, go-arounds, and touch-and-go landings. After a normal go-around due to excessive crosswinds, they initiated a no-flap landing for the next attempt. As the student pilot established the airplane on short final, he attempted to arrest the airplane’s descent by increasing engine power, but the engine did not respond. The instructor told the student pilot to “push it back in to add power,” and the student pilot pulled and pushed the throttle several times to try to increase engine power. After several unsuccessful attempts to increase engine power, the instructor took control of the airplane and attempted a forced landing. The airplane touched down short of the runway, bounced hard, and struck the landing lights before landing back on the runway. The airplane’s airframe sustained substantial damage. Postaccident examination of the airplane revealed an obstructed right trailing edge fuel vent line that likely blocked venting of the fuel tank and resulted a negative pressure within the tank, whichsubsequently starved the engine of fuel and resulted a total loss of engine power. The airplane's flight manual specified that during a preflight inspection, the fuel vent line should be checked for any obstructions, but the flight instructor did not witness the student pilot conduct the preflight inspection of the airplane. It is likely that the student pilot did not detect the blocked vent line during the preflight inspection; had more direct supervision been provided by the flight instructor during the preflight inspection, the blockage would have been discovered.

Factual narrative

On September 10, 2019, about 1220 central daylight time, a Beech A-23, N3555R, was substantially damaged during a forced landing at Northwest Florida Beaches International Airport (ECP) Panama City, Florida. The student pilot/owner and flight instructor were not injured. The airplane was registered to and operated by the student pilot under the provisions of Title 14 Code of Federal Regulations as a part 91 instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that departed South Alabama Regional Airport at Bill Benton Field (79J) Andalusia, Alabama about 1130. The student pilot and his flight instructor had just completed a cross country flight from ECP to 79J, then back to ECP and were conducting airport traffic pattern work, go-arounds and touch and go landings to runway 16. After a normal go-around due to excessive crosswinds, they initiated a no-flap landing for the next attempt. As the student pilot became established on short final, he reported that the approach was normal, but when he attempted to arrest his descent by increasing engine power, the engine did not respond. The student pulled and pushed the throttle several times and the instructor told him to immediately "push it back in to add power." The instructor's first thought was that the throttle cable had broken. After several unsuccessful attempts to regain engine power, the instructor took control of the airplane and attempted a landing, but touched down short of the runway; the airplane bounced hard, struck the approach lights, then settled back onto the runway before rolling to a stop. According to Federal Aviation Administration (FAA) airmen records, the flight instructor held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, instrument airplane. She also held a flight instructor certificate with ratings for airplane single engine land instrument airplane. She reported 3,150 hours total time and was issued an FAA second-class medical certificate in May 1, 2019. The student pilot/owner reported 36.1 hours total time with 6.1 hours in the accident airplane make and model and was issued an FAA third-class medical certificate on August 30, 2017. According to FAA airworthiness and maintenance records, the airplane was issued a standard airworthiness certificate on April 12, 1965. It was a four-place, internally braced low-wing airplane, that was equipped with fixed tricycle landing gear, and a Continental IO-346A, 165-horsepower engine driving a two-blade metal fixed pitch propeller. The airframe and engine had accumulated 3,023 hours total time; the engine accumulated 669 hours total time since overhaul as of the last annual inspection on April 2, 2019. The student pilot purchased the airplane on May 10, 2017. The weather conditions reported at ECP at 1153 included winds 080° at 7 knots, visibility 10 statute miles, scattered clouds at 4,500 ft, temperature 34° C, dew point 22° C,and an altimeter setting of 30.18 inches of mercury. Postaccident examination of the airplane revealed that the right wing spar was damaged, and the upper and lower areas on the right wing were buckled. The right gear fairing was buckled, and the left wing was wrinkled where the gear assembly was attached and resulted in damage to the left wing spar. Examination of the airplane's fuel venting system by a mechanic revealed foreign object debris with the consistency of dirt obstructing the right trailing edge fuel vent line. Upon closer examination, it was revealed that the fuel tank vent tube was clogged with mud from an insect, commonly referred to as a "Mud Dauber" wasp. According to the manufacturer's Airplane Flight Manual (AFM), under Section IV Normal procedures, the preflight inspection includes a specific line item to ensure that the right wing trailing edge, fuel tank vent line, is unobstructed. The flight instructor stated that she did not witness the student pilot conduct the preflight inspection of his airplane.

Aircraft

Registration
N3555R
Reported as
Beech 23 (A23)
Category
Airplane
Serial number
M-729
Built
1965
Airframe hours
3,023.1
Engine
Continental IO-346A, 165 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · April 2, 2019 · 3 hours before
Departed
ECP · Panama City, FL
Destination
ECP · Panama City, FL
Airport
ECP · Northwest Florida Beaches Intl, runway 16, 10,000 × 150 ft, concrete
Equipment
Handheld GPS, 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Injuries
None
Certificate
Student
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
36 total · 6 in this make and model
Role
Flight instructor
Age
59
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 1, 2018
Seat
Right
Flight hours
3,150 total · 15 in this make and model · 80 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 7 knots
Visibility
10 statute miles
Temperature
93 °F, dew point 72 °F
Altimeter
30.18 inHg
Observed at
ECP, 1 nm away

Docket · 6

The files NTSB released with the investigation on September 8, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.2 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.