# NTSB ERA20LA052: Beech 55, N9404Q, Grove City, PA, October 1, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 1, 2019, 12:00 local (16:00 UTC) - Place: Grove City, PA - Coordinates: 41.14611, -80.168052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.1461&lon=-80.1681&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel related](https://openairdocs.org/ntsb-events/190) - 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): 100679 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA052 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100679/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100679 - Page: https://openairdocs.org/ntsb/ERA20LA052 ## Probable cause The pilot’s mismanagement of the airplane’s available fuel, which resulted in a partial loss of engine power to the left engine, and his subsequent failure to maintain directional control of the airplane while on final approach to the runway. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (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) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 95-B55 (T42A), 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1152706), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 95-B55 (T42A), 4 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1152706), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 95-B55 (T42A), 17 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152706), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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 related](https://openairdocs.org/ntsb-events/190) (defining event); 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) - [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Beech 95-B55 (T42A), 16 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152706), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot of the twin-engine airplane was returning to the departure airport and was on final approach to the runway at an altitude of about 200 ft above ground level. The pilot believed that the airplane was approaching the runway too low and increased power to the engines, but the left engine did not respond as he expected. The pilot attempted to maintain directional control of the airplane, but the airplane impacted the grass to the left of the runway, resulting in substantial damage to the fuselage. A postaccident examination of the airplane revealed that the left fuel selector was positioned to the main tank, where about 4.6 gallons of fuel (3.5 gallons of which was usable) were present. One ounce of fuel was found in the main fuel line to the left engine, and “one drop” of fuel was found in the fuel line to the fuel flow divider. Examination of the left engine otherwise revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation at the time of the accident. The pilot provided conflicting statements describing of the events that transpired on the day of the accident regarding the flight’s itinerary and the amount of fuel onboard the airplane. Given that the postaccident examination of the engine showed no discrepancies, and that only trace amounts of fuel were found in the fuel system and engine, it is most likely that the pilot did not adequately manage the available fuel supply, which resulted in the reported loss of left engine power while on final approach to the runway. The pilot subsequently failed to maintain directional control of the airplane during the events that followed, which ultimately resulted in impact with terrain. ## Factual narrative On October 1, 2019, at 1200 eastern daylight time, a Beech 55, N9404Q, was substantially damaged when it was involved in an accident at Grove City Airport (29D), Grove City, Pennsylvania. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. In a written report of the accident, the pilot stated that he departed from 29D around 1000, and that the airplane’s fuel state at takeoff was “1/4 tank.” He then flew to Greenville Municipal Airport (4G1), Greenville, Pennsylvania, where he visited with the airport manager before returning to 29D. The pilot described that while on final approach to land, he felt the airplane was low and he “gave the airplane some power.” The left engine then “sputtered and surged.” The pilot further described that, “it did not quit but it was not making power.” The airplane was near the end of the runway and at an altitude of about 200 ft above the ground. The pilot stated that he then used the right rudder to get the airplane under control and that it was 10° left of course. Because the airplane was heading towards the occupied airport ramp, he decreased power to the right engine, decreased the pitch, and the airplane impacted the ground and slid to a stop. In a subsequent interview with a Federal Aviation Administration (FAA) inspector the pilot stated that he departed 29D with an unknown quantity of fuel and flew to 4G1, which was a 10-minute flight. The pilot described that he overflew the airport to see if a mechanic friend was there; because his friend was not there, the pilot began the return trip to 29D. At that point, the pilot noted that the airplane had about one-eighth tank of fuel in both fuel tanks. The FAA inspector also spoke with airport management personnel at 29D, who reported that the pilot's credit card was charged twice at the airport's self-service fuel pump the day after the accident. The first charge, at 1052, was for 5.5 gallons; the second charge, at 1008, was for 5.5 gallons. The accident was not reported to the FAA or the NTSB until December 10, 2019. Subsequent examination of the wreckage by an FAA inspector revealed that the fuselage had been substantially damaged. The fuel selectors were positioned to the left and right main tanks. The left wing's main fuel tank had 4.6 gallons of fuel (3.5 gallons of which was usable), and the auxiliary tank contained 2 gallons of fuel. The left engine's main fuel feed line was disconnected from the firewall, and 1 ounce of fuel was collected. The fuel was placed in a glass container and was observed to be absent of debris and water. The fuel line to the flow divider was removed, and “one drop” of fuel was observed. The digital left fuel gauge indicated a total of 7 gallons of fuel. Examination of the left engine revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. ## Aircraft - Registration: [N9404Q](https://openairdocs.org/deregistered/N9404Q-2022-07-02), registration cancelled 2022-07-02, S/N TC-1352, built 1970 (OpenAirDocs) - Reported make and model: Beech 55 (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-1352 - Year built: 1970 - Engines: Continental IO-470 260 horsepower reciprocating; Continental IO-470 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 15, 2019 - Departed: 29D, Grove City, PA - Destination: 29D, Grove City, PA - Airport: 29D, Grove City, runway 28, 4,500 × 75 ft, asphalt - Equipment: Onboard weather, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: none; commercial, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; restraint: 4-point; flight hours: 3,020 total, 25 in this make and model, 3,020 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 66 °F - Altimeter: 30.04 inHg - Observed at: KUCP, 13 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 20191001020719A](https://openairdocs.org/incident/20191001020719A), Oct 1, 2019: Beech 95-B55 (T42A), Grove City, PA, Substantial damage. Airman flew from Grove City Airport to greenville airport (overflew with no stop) with a flight duration of ten minutes. Airman stated at one point during his… ## Docket (7 files) The files NTSB released with the investigation on May 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100679. 12.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8961122&FileExtension=pdf&FileName=NTSB%20Form%206120_Redacted-Rel.pdf - Pilot's statement (item 2, PDF, 1 page, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9001114&FileExtension=pdf&FileName=Memorandum%20of%20Record%20-%20Long-Rel.pdf - Summary for record- FAA inspectors (item 3, PDF, 2 pages, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9069588&FileExtension=pdf&FileName=Summary%20for%20Record-%20FAA%20Inspectors-Rel.pdf - Photo array (item 4, PDF, 4 pages, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8961089&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Airplane photos (item 5, PDF, 15 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9001064&FileExtension=pdf&FileName=N9404Q%20Aircraft%20Photos_Redacted-Rel.pdf - Maintenance records (item 6, PDF, 9 pages, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9000703&FileExtension=pdf&FileName=Aircraft%20Logs_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 944 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8961340&FileExtension=pdf&FileName=NTSB%20%20Wreckage%20Release%20N9404Q_Redacted-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.