# NTSB ERA20LA313: Beech A36, N74HS, Jackson, TN, September 11, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: September 11, 2020, 02:52 local (07:52 UTC) - Place: Jackson, TN - Coordinates: 35.584445, -88.940002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.5844&lon=-88.9400&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO, Textron Aviation, Continental Aerospace - NTSB case key (mKey): 101948 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA313 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101948/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101948 - Page: https://openairdocs.org/ntsb/ERA20LA313 ## Probable cause The pilot’s inadequate preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's impairment due to alcohol. ## 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; cases with it: [Beech A36, 22 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151604), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot; cases with it: [Beech A36, 9 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151604), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Impairment/incapacitation: alcohol](https://openairdocs.org/ntsb-findings/02012015): Personnel issues › Physical · Pilot; cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-findings/02012015/cases.md?model=1151604), [All aircraft, 87 cases](https://openairdocs.org/ntsb-findings/02012015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=1151604), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airplane was enroute during a night cross-country flight when the pilot reported to air traffic control that he was low on fuel and needed to divert to a nearby airport. The controller approved the pilot’s request, and there were no additional communications from the pilot. The wreckage of the airplane was later located in a wooded area near the divert airport. Examination of the airframe and engine revealed no evidence of fuel at the accident scene and no evidence of pre-accident anomalies that would have precluded normal operation of the airplane before the accident. Fuel computations based on refueling records, previous flights, and estimated fuel burn rates showed the engine likely consumed all usable fuel onboard. Additionally, data downloaded from an onboard engine monitor recorded the fuel flow decreasing to zero about 6 minutes before the data ended. The pilot’s report to air traffic control that he was low on fuel, the onboard engine monitor data showing fuel flow drop to zero, and the lack of fuel at the accident scene all indicate the pilot departed with insufficient fuel onboard to complete his planned flight. This resulted in a total loss of engine power due to fuel exhaustion and impact with terrain. The pilot’s toxicology showed that ethanol was present in his femoral blood at nearly three times the regulatory limit for flying. Ethanol was also present in the pilot’s vitreous indicating that the ethanol was likely from ingestion and representative of his blood alcohol level at the time of the crash. Vitreous is relatively unsusceptible to postmortem ethanol production, and the measured proportion of ethanol in vitreous compared to femoral blood fits a typical pattern seen after consumed ethanol is absorbed. The pilot’s decision to fly with insufficient fuel to reach his destination was consistent with the known impairing effects of ethanol on awareness, decision making, and performance. Thus, effects from ethanol likely contributed to the accident. ## Factual narrative On September 11, 2020, about 0252 central daylight time, a Beech A36, N74HS, was substantially damaged when it was involved in an accident near McKellar-Spies Regional Airport (MKL), Jackson, Tennessee. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to FAA inspectors, the evening before the accident, the pilot flew the airplane from Charles W Baker Airport (2M8), Millington, Tennessee, which was his home airport, to Dickson Municipal Airport (M02), Dickson, Tennessee, arriving about 2035 on September 10, 2020. According to the manager at M02, surveillance video showed that upon arrival, the airplane taxied to the fuel farm, and the pilot exited the airplane and walked up to the fuel pump. He then returned to the airplane, started it, and taxied to the parking area. The manager stated that the fuel farm was operated by the fixed-base operator (FBO), and the pump was locked. The manager further stated that there was a sign on the FBO door advising anyone looking to purchase fuel to call an afterhours telephone number for service. The M02 surveillance video showed the airplane about 0200 on September 11, 2020, taxiing back to the fuel farm, but the pilot did not exit the airplane. The airplane remained idling for about 3 minutes outside the fuel farm and departed the airport about 0206. According to the FAA, the pilot had filed a visual flight rules (VFR) flight plan from M02 to 2M8. About 0248, the pilot requested a deviation from air traffic control to land at MKL. He advised the controller that he was experiencing a fuel issue, stating “we’re just a little low on fuel,” and needed to land. The controller provided a heading vector towards MKL and asked the pilot to report when he had the airport in sight. The pilot turned to the new heading, and flight track data showed the airplane began a descent from about 6,000 ft. No further communications were received from the pilot, and the last flight track data point recorded was at 0252 at an altitude of 525 ft. The Federal Aviation Administration (FAA) subsequently issued an Alert Notice (ALNOT), and the airplane was located later that morning about 1.5 miles west of MKL in a wooded area. An inspection of the accident site by FAA inspectors revealed that the airplane had impacted trees and terrain and that all major components of the airplane were located at the accident site. The airplane was substantially damaged with the engine, propeller, and nose gear separated at the firewall and the right wing separated near the fuselage. There was no odor of fuel at the accident site. No fuel was found in the left fuel tank, and it was not breached. The right fuel tank was breached. The fuel inlet line attached to the manifold valve was removed and was absent of fuel. A trace amount of fuel was found in the engine driven fuel pump inlet line. Further examination of the airframe and engine after recovery revealed no evidenceof any preimpact mechanical malfunctions or failures that would have precluded normal operation. A JPI engine data monitor was recovered from the wreckage and downloaded by the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory. Fuel flow rates indicated that about 0245, the flow dropped from 8.3 gallons per hour to 6 gallons per hour and then to 0. Fuel flowed intermittently at rates of 0.2 to 0.4 gallons per hour until 0247, at which time the fuel flow dropped to 0 and remained there until the engine data monitor stopped recording at 0251. FAA inspectors collected the fueling records for the airplane and verified them using the pilot’s credit card statement records. The last known refueling event was on August 23, 2020, when the airplane was fueled with 43.0 gallons of 100LL aviation fuel at 2M8 airport. The airplane was flown 5.1 hours between the last refueling and the accident. The airplane had a usable fuel capacity of 74 gallons, which provided about 5 hours of flight time at a fuel burn rate of 15 gallons per hour. The Office of the Medical Examiner, Center for Forensic Medicine, Nashville, Tennessee, performed the pilot’s autopsy. According to the autopsy report, the cause of death was multiple blunt force injuries. The autopsy did not identify any significant natural disease. Two laboratories performed toxicological testing on specimens from the pilot. One laboratory identified ethanol at 0.119 grams per deciliter (g/dL) in femoral blood and 0.149 g/dL in vitreous. The other laboratory identified ethanol at 0.103 g/dL in cavity blood and 0.156 g/dL in vitreous. Ethanol is the intoxicating alcohol in beer, wine, and liquor. It can impair judgment, psychomotor performance, cognition, perception, and vigilance. FAA regulation prohibits any person from acting as a crewmember of a civil aircraft within 8 hours of consuming an alcoholic beverage or while having a blood ethanol level of 0.04 g/dL or greater. In general, the number and seriousness of pilot errors increase with blood ethanol level. Ethanol can also be produced by microbes in a person’s body after death. ## Aircraft - Registration: [N74HS](https://openairdocs.org/deregistered/N74HS-2021-09-04), registration cancelled 2021-09-04, S/N E-2659, built 1991 (OpenAirDocs) - Reported make and model: Beech A36 (UNDESIGNAT) - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-2659 - Year built: 1991 - Engines: Continental IO-550-B (45) 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Departed: M02, Dickson, TN - Destination: MKL, Jackson, TN - Flight plan: VFR - Airport: MKL, Mc Kellar-Sipes Rgnl - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 366 total, 200 in this make and model ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 5 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 64 °F - Altimeter: 30.12 inHg - Observed at: MKL, 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 20200911011889A](https://openairdocs.org/incident/20200911011889A), Sep 11, 2020: Beech A36, Jackson, TN, Destroyed, 1 fatal. On September 11, 2020, about 0252 central daylight time, a Beech A36, N74HS, was destroyed when it was involved in an accident near mckellar-sipes regional… ## Docket (15 files) The files NTSB released with the investigation on September 27, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101948. 8.4 MB in all. - Airport (M02) manager statement (item 1, PDF, 3 pages, 359 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13196720&FileExtension=pdf&FileName=1_Memorandum%20for%20Record-Airport%20Mgr%20statement_Redacted-Rel.pdf - Record of conversation - FAA inspector (item 2, PDF, 1 page, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14491793&FileExtension=pdf&FileName=Record%20of%20Conversation_FAA_N74HS-Rel.pdf - Fueling recorders (item 3, PDF, 2 pages, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13195877&FileExtension=pdf&FileName=2_Fuel%20recorders_Redacted-Rel.pdf - Pilot operating handbook excerpt - fuel system (item 4, PDF, 2 pages, 978 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13222489&FileExtension=pdf&FileName=Beech%20A36%20POH%20Excerpt-Rel.pdf - ATC recording (item 5, MP4, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13195555&FileExtension=mp4&FileName=ZME%209-11-2020%20N74HS%20FATAL-Rel.mp4 - Memorandum for record - ATC transcript (item 6, PDF, 1 page, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13196422&FileExtension=pdf&FileName=Memorandum%20for%20Record-excerpts%20from%20ATC-Rel.pdf - Airplane flight path (item 7, PDF, 1 page, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13221698&FileExtension=pdf&FileName=Airplane%20Flight%20Path-Rel.pdf - Flight track data (item 8, CSV, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13221175&FileExtension=csv&FileName=3_Flt%20Track%20data%20_N74HS%20CSV-Rel.csv - Investigative photographs (item 9, PDF, 7 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13216819&FileExtension=pdf&FileName=Investigative%20Photographs%20-%20ERA20LA313-Rel.pdf - NTSB medical factual report (item 10, PDF, 3 pages, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13195300&FileExtension=pdf&FileName=ERA20LA313_MedicalFactualReport-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11655068&FileExtension=pdf&FileName=Tox_ERA20LA313_Redacted-Rel.pdf - Mor - medical and pathological info (item 12, PDF, 1 page, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11654928&FileExtension=pdf&FileName=Memorandum%20for%20Record-Medical%20and%20Pathological%20Information_ERA20LA313-Rel.pdf - Engine tabular data (item 13, CSV, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13222105&FileExtension=csv&FileName=JPI%20Data-Rel.csv - Statement of party representation (item 14, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13195310&FileExtension=pdf&FileName=Textron%20Aviation%20Party%20Form_Redacted-Rel.pdf - Wreckage release (item 15, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13196111&FileExtension=pdf&FileName=N74HS%20Wreckage%20Release_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.