# NTSB ERA19TA276: Beech 23, N3555R, Panama City, FL, September 10, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Final report - Date: September 10, 2019, 12:20 local (17:20 UTC) - Place: Panama City, FL - Coordinates: 30.358333, -85.795555 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.3583&lon=-85.7956&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 100294 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19TA276 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100294/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100294 - Page: https://openairdocs.org/ntsb/ERA19TA276 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1151204), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1151204), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Object/animal/substance: debris/dirt/foreign object](https://openairdocs.org/ntsb-findings/03022055): Environmental issues › Physical environment · Awareness of condition (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/03022055/cases.md?model=1151204), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/03022055/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=1151204), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=1151204), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech A23, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151204), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-events/092/sequence.md?model=1151204), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A23, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151204), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N3555R-2022-01-08), registration cancelled 2022-01-08, S/N M-729, built 1965 (OpenAirDocs) - Reported make and model: Beech 23 (A23) - Registry model: [Beech A23](https://openairdocs.org/model/beech-a23) (registry code 1151204) (OpenAirDocs) - Registry engine: [Continental IO-346 series](https://openairdocs.org/engine/continental-io-346-series) (registry code 17033, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-729 - Year built: 1965 - Airframe hours: 3023.1 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; restraint: lap only; flight hours: 36 total, 6 in this make and model - Flight instructor; age 59; injuries: none; 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 ## 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 20190910014579A](https://openairdocs.org/incident/20190910014579A), Sep 10, 2019: Beech A23, Panama City, FL, Substantial damage. Flight was a 14 CFR 91 instructional flight when the accident occurred. Aircraft was on final when the student pilot tried to add power but the engine did not… ## Docket (6 files) The files NTSB released with the investigation on September 8, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100294. 4.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486746&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspectors Statement (item 2, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486747&FileExtension=.PDF&FileName=FAA%20Inspectors%20Statement-Master.PDF - Record of Conversation-Flight Instructor (item 3, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486748&FileExtension=.PDF&FileName=Record%20of%20Conversation-Flight%20Instructor-Master.PDF - Record of Conversation_Mechanic (item 4, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486749&FileExtension=.PDF&FileName=Record%20of%20Conversation_Mechanic-Master.PDF - Photo Array_Airplane Damage (item 5, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486750&FileExtension=.PDF&FileName=Photo%20Array_Airplane%20Damage-Master.PDF - Airplane Flight Manual Excerpt_Preflight Inspection (item 6, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486751&FileExtension=.PDF&FileName=Airplane%20Flight%20Manual%20Excerpt_Preflight%20Inspection%20-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.