# NTSB ERA21FA237: Beech A23, N8780M, Pinnacle, NC, June 1, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 1, 2021, 17:20 local (21:20 UTC) - Place: Pinnacle, NC · 2,500 by 2,500 foot field - Coordinates: 36.34076, -80.39283 - Nearby events: https://openairdocs.org/map.md?lat=36.3408&lon=-80.3928&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Textron - NTSB case key (mKey): 103191 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21FA237 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103191/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103191 - Page: https://openairdocs.org/ntsb/ERA21FA237 ## Probable cause The flight instructor’s mismanagement of the available fuel, which resulted in a total loss of engine power due to fuel starvation. ## 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 management; cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151204), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Instructor/check pilot; cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151204), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=1151204), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151204), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-flare/touchdown: Dragged wing/rotor/float/other](https://openairdocs.org/ntsb-events/093); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-events/093/sequence.md?model=1151204), [All aircraft, 319 cases](https://openairdocs.org/ntsb-events/093/sequence.md) - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=1151204), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## Analysis The student pilot and flight instructor departed on a local training flight. After about 39 minutes, the engine lost total power. Flight track information indicated that the airplane continued to descend, and the last flight track target showed the airplane descending through 1,075 ft mean sea level (msl) at a groundspeed of 64 knots. The elevation at the accident site was about 1,000 ft. The airplane impacted a grass field and sustained substantial damage to the wings and fuselage. Review of the airplane’s flight log indicated that the airplane flew 2.8 hours since it was most recently fueled to capacity (58.8 gallons usable) one week before the accident, and that the airplane departed on the accident flight with the left-wing tank about 2/3 full and the right-wing tank about 1/2 full. The fuel consumption indicated by the flight log was consistent with about 14 gallons per hour. Postaccident examination of the engine and fuel system revealed that the left main fuel tank was breached; the right fuel tank, which remained intact, contained about 1 pint of fuel. The fuel selector was in the right tank position. Portions of the fuel system contained a trace amount of fuel, and no fuel was found in the fuel flow divider. When tested, the electric boost pump functioned normally. Other than the absence of fuel, no anomalies were noted with the engine that would have precluded normal operation. Based on the available information, it is likely that the loss of engine power was the result of fuel starvation when the fuel supply in the right tank was exhausted. The procedure for a loss of engine power in the pilot operating handbook included switching the fuel tanks; had the flight instructor switched the fuel selector from the right to the left-wing tank, it is likely that engine power would have been restored. ## Factual narrative On June 1, 2021, about 1720 eastern daylight time, a Beech A23, N8780M, was substantially damaged when it was involved in an accident near Pinnacle, North Carolina. The student pilot was fatally injured and the flight instructor sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that, after performing a series of maneuvers, while transitioning between practice areas, the engine lost total power. After multiple attempts to restart the engine, she performed a forced landing to a field. A review of the flight track data revealed that the flight departed runway 22 at Smith Reynolds Airport (INT), Winston Salem, North Carolina, about 1641. The airplane made a right turn and tracked northwest, then east, performing a series of turns, climbs, and descents, consistent with maneuvering flight. About 1718, while flying on an easterly track, the airplane entered a right descending 270° turn from about 2,100 ft mean sea level (msl). The last target was observed at 1719 as the airplane descended through 1,075 ft msl at a groundspeed of 64 knots, about 16 miles northwest of INT. The elevation at the accident site was about 1,000 ft. The airplane impacted a grass field on a residential property. The wreckage debris path was about 65 ft long and oriented on a magnetic heading of 162°. There was no postimpact fire and all major structural components of the airplane were located within the debris field. All flight control cables were continuous from the cockpit controls to the control surfaces. Manual manipulation of the aileron, stabilator, and rudder cables operated their respective control surfaces. The outboard portion of the left wing came to rest inverted and next to the inboard portion of the wing. The left wing was impact-separated from the fuselage at the wing root, the aileron cables remained attached. The empennage separated from the fuselage and came to rest behind the cabin, the elevator and rudder cables remained attached. The engine was partially separated; the fuel hoses, throttle, and mixture control cables remained attached. The nose and right main landing gear were separated. The engine fuel supply system remained intact. The fuel boost pump switch lever was fracture-separated, but the remaining portion was in the “ON” position. The left fuel tank was breached, the right fuel tank remained intact and contained about 1 pint of aviation fuel that was free of water and debris. Grass blighting was evident at the initial left wing impact location and continued along the wreckage path to the main wreckage. The fuel flow divider and fuel injector lines did not contain any fuel. The fuel injectors and fuel flow divider were disassembled and found to be free of debris. The fuel line from the engine-driven fuel pump to the fuel metering assembly contained fuel and the line from the fuel metering assembly to the flow divider contained a small amount offuel. The fuel selector was in the right tank position, and the valve contained a small amount of fuel. The fuel outlet strainers in each wing, and all fuel supply lines and vents were free of obstructions. None of the fuel supply lines from the firewall forward were breached. The electric fuel boost pump was removed and hooked up to a power supply; it was successfully operated and pumped water. Both magnetos were removed and manually operated. The right and left magnetos produced spark on all leads. The top spark plugs were in new condition when compared to a Champion Spark Aviation Check-A-Plug chart AV-27. The engine was manually rotated; continuity was confirmed and thumb compression was verified on all cylinders. Each of the cylinder valves appeared well lubricated and their associated rockers and springs functioned smoothly. There were 6 quarts of oil inside the crankcase. The oil filter was cut open and the filter pleats were free of any ferrous material or debris. The propeller remained attached to the crankshaft flange. Blade A was unremarkable, and Blade B was uniformly bent aft around the engine. Blade B was cut from the hub to facilitate engine rotation. Neither blade exhibited leading edge gouging or polishing. According to the airplane flight log, the airplane flew 2.8 hours since it was last fueled to capacity one week before to the accident. After 1 flight hour, the left and right fuel tanks were “1/2 and FULL,” respectively. After the next flight, just over 1 hour, the fuel tanks were “2/3 and 1/2”, the same as the preflight fuel level for the accident flight. The flight instructor noted that they departed on the accident flight with about 30 gallons of fuel. The airplane was equipped with a 59.8-gallon fuel system, of which 58.8 gallons were usable. Each wing tank had a capacity of 29.9 gallons. The average fuel consumption was about 9 gallons per hour (gph), with higher amounts for takeoff and climb; however, according to the flight log, the airplane was consuming about 14 gph. The pilot operating handbook (POH) stated that the fuel return line from the engine-driven fuel pump returns about 3 to 6 gallons of fuel per hour to the left tank when the engine is operating at 75% power or less. The POH outlined the following emergency procedures in the event of an engine failure after liftoff and in flight if sufficient altitude was available for maneuvering: Fuel Selector Valve – SELECT OTHER TANK (Check to feel detent) Auxiliary Fuel Pump – ON Mixture – FULL RICH, then LEAN as required Magnetos – CHECK LEFT and RIGHT, then BOTH NOTE The most probable cause of engine failure would be loss of fuel flow or improper functioning of the ignition system According to the Federal Aviation Administration Airplane Flying Handbook (FAA-H-8083-3B), the key to successful management of an emergency situation, and/or preventing a non-normal situation from progressing into a true emergency, is a thorough familiarity with, and adherence to, theprocedures developed by the airplane manufacturer and contained in the POH/AFM. ## Aircraft - Registration: [N8780M](https://openairdocs.org/aircraft/N8780M), registered now, S/N M-564 (OpenAirDocs) - Reported make and model: BEECH 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-564 - Year built: 1964 - Airframe hours: 3643.43 - Engines: CONT MOTOR IO-346 SERIES 165 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 19, 2021, 23.82 hours before - Departed: INT, Winston Salem, NC - Equipment: Stall warning system, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 31; injuries: fatal; student; medical: class 1, without waivers/limitations; seat: left; restraint: lap only; toxicology performed; flight hours: 12 total, 12 in this make and model, 5 in the last 30 days - Flight instructor; age 24; injuries: serious; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review December 8, 2020; seat: right; toxicology performed; flight hours: 606.2 total, 8.4 in this make and model, 493.1 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 4 knots - Visibility: 10 statute miles - Temperature: 75 °F, dew point 55 °F - Altimeter: 30.25 inHg - Observed at: MWK, 11 nm away - METAR: KMWK 012015Z AUTO 20004KT 10SM SCT049 24/13 A3025 RMK AO2 T02410125 ## 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 20210601007409A](https://openairdocs.org/incident/20210601007409A), Jun 1, 2021: Beech A23, Pinnacle, NC, Destroyed, 1 fatal. N8780M suffered engine loss for unknown reasons. Fuel selector was found on the right fuel tank and the magneto switch was found in the off position. Aircraft… ## Docket (12 files) The files NTSB released with the investigation on February 1, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103191. 202 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 912 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13811835&FileExtension=pdf&FileName=NTSB%20report_Redacted-Rel.pdf - Witness statements (item 2, PDF, 2 pages, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15020196&FileExtension=pdf&FileName=Witness%20Statements-Rel.pdf - Flight track (item 3, PDF, 1 page, 893 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13841713&FileExtension=pdf&FileName=ERA21FA237%20-%20Flight%20Track-Rel.pdf - Flight track data - tabular (item 4, CSV, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13815987&FileExtension=csv&FileName=ERA21FA237%20-%20OV%20Track%20Data-Rel.csv - Maintenance records (item 5, PDF, 9 pages, 195 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13798387&FileExtension=pdf&FileName=Maintenance%20logbooks_Redacted-Rel.pdf - Fuel records (item 6, PDF, 2 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13816530&FileExtension=pdf&FileName=Fuel%20Records_Redacted-Rel.pdf - POH fuel system excerpt (item 7, PDF, 7 pages, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13810601&FileExtension=pdf&FileName=POH%20Fuel%20System-Rel.pdf - Mfr autopsy report (item 8, PDF, 1 page, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13776379&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20Autopsy-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 14 pages, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12373625&FileExtension=pdf&FileName=NTSB%20Signed%20Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13773077&FileExtension=pdf&FileName=Retention-Release-of-Wreckage-Form%20Signed-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 699 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13773942&FileExtension=pdf&FileName=Toxicology%20Report_Redacted-Rel.pdf - Investigative photographs (item 12, PDF, 7 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13834017&FileExtension=pdf&FileName=Photos-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.