# NTSB ERA20LA018: Beech N35, N564T, Madisonville, TN, October 18, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 18, 2019, 15:30 local (19:30 UTC) - Place: Madisonville, TN - Coordinates: 35.550556, -84.374443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.5506&lon=-84.3744&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/ FSDO - NTSB case key (mKey): 100473 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA018 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100473/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100473 - Page: https://openairdocs.org/ntsb/ERA20LA018 ## Probable cause The pilot's unstable approach and delayed decision to go-around. Contributing to the accident was the unporting of the fuel supply following a forward slip maneuver during the approach, which resulted in the loss of engine power during the go-around. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151528), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=1151528), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech N35, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=1151528), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=1151528), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech N35, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151528), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-events/380/sequence.md?model=1151528), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Approach-VFR go-around: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech N35, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151528), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech N35, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151528), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, during a simulated loss of engine power landing, the airplane was too fast and high, so he performed a forward slip to the left to increase the descent rate. The airplane touched down on the runway with less than 1/3 of its distance remaining and immediately bounced back into the air. The pilot added power to initiate a go-around; however, the engine did not respond, and the airplane subsequently descended into trees and terrain beyond the departure end of the runway, resulting in substantial damage to both wings. Examination revealed no anomalies with the airframe or engine that would have precluded normal operation, and the engine produced normal power during a test run. Thus, it is likely that the fuel unported from the right tank following the forward slip to the left, and the fuel supply was interrupted as the pilot attempted the go-around. The accident would have likely been prevented if the pilot had performed a go-around earlier during the approach, when he realized that the airplane was too high and too fast to safely land on the available runway. ## Factual narrative On October 18, 2019, about 1530 eastern daylight time, a Beech N35 airplane, N564T, impacted terrain and trees during a go-around at Monroe County Airport (MNV), Madisonville, Tennessee. The private pilot was not injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during the approach to MNV he decided to perform a training exercise by simulating an engine failure during the landing. He entered the traffic pattern for runway 5 and reduced power to idle; while on final approach he reported that the airplane was "a little fast and a little high" so he performed a forward slip to the left (left rudder application) for a "second or two." He continued the approach and the airplane touched down with about 1,000 ft of the 3,643 ft runway remaining and immediately bounced back into the air. The pilot decided to perform a go-around and applied power; however, the engine did not respond. The airplane flew beyond the departure end of the runway, touched down in grass, and skidded into shrubs and trees. The left and right wings sustained substantial damage. Postaccident, the pilot reported that he believed the slip maneuver "unported fuel from the right tank [selected tank for approach] and prevented the plane from throttling up." He reported that there were no mechanical malfunctions or failures with the airplane. Examination of the airplane by a Federal Aviation Administration inspector found no preimpact mechanical malfunctions or failures that would have precluded normal operation. There were no obstructions or debris found in the fuel system and the engine produced normal power when it was test run. Inspection revealed 17 gallons of fuel in the right tank and 22 gallons in the left tank. The airplane flight manual stated in part: FUEL CELLS Fuel supply is carried in two bladder-type cells with a total capacity of [40 gallons, optional fuel system installed], located in the wings just outboard of the fuselage. Fuel is fed from the cells to a selector valve just forward of the front seat, on the left side, then through a strainer to the fuel pump and the engine. The fuel tank fillers are located in the wing leading edges. Maximum Slip Duration: 30 seconds for airplanes with baffled main fuel cells in both wings. ## Aircraft - Registration: [N564T](https://openairdocs.org/aircraft/N564T), registered now, S/N D-6744, built 1961 (OpenAirDocs) - Reported make and model: Beech N35 (NO SERIES) - Registry model: [Beech N35](https://openairdocs.org/model/beech-n35) (registry code 1151528) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-6744 - Year built: 1961 - Airframe hours: 11026 - Engines: Continental IO-470-N 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2019 - Departed: T73, Lancaster, SC - Destination: MNV, Madisonville, TN - Flight plan: IFR - Airport: MNV, Monroe County, runway 05, 3,643 × 75 ft, asphalt - Equipment: Onboard weather, ADS-B, Satellite tracking device, Stall warning system, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 22, 2018; seat: left; restraint: 4-point; flight hours: 583 total, 506 in this make and model, 556 as pilot in command, 27 in the last 90 days, 5 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 37 °F - Altimeter: 29.97 inHg - Observed at: KMNV ## 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 20191018022389A](https://openairdocs.org/incident/20191018022389A), Oct 18, 2019: Beech N35, Madisonville, TN, Substantial damage. This flight originated from T73 south carolina. Pilot states that he picked up an IFR flight plan shortly after take off. The flight was conducted under ATC… ## Docket (5 files) The files NTSB released with the investigation on June 10, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100473. 6.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484228&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - NTSB Memo for Record - FAA Engine Exam (item 2, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484229&FileExtension=.PDF&FileName=NTSB%20Memo%20for%20Record%20-%20FAA%20Engine%20Exam-Master.PDF - Record of Conversation (Pilot) (item 3, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484230&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot)-Master.PDF - Photo Array (item 4, .PDF, 947 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484231&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Airplane Flying Handbook Excerpts (item 5, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484232&FileExtension=.PDF&FileName=Airplane%20Flying%20Handbook%20Excerpts-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.