ERA22LA033

NTSB accident investigation · Beech 23 · Ballston Spa, NY · October 27, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 27, 2021, 17:50 local (21:50 UTC)
Place
Ballston Spa, NY
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2353ZBeech 23
Defining event
Approach-VFR pattern final: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20211027020779A
Case key
104171

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor’s and student pilot’s inadequate preflight fuel planning and improper in-flight fuel management, which resulted in a total loss of engine power due to fuel starvation.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Planning/preparation: fuel planningPersonnel issues › Task performance · Instructor/check pilotBeech 23: 3 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelBeech 23: 3 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · Student/instructed pilotBeech 23: 3 casesAll aircraft: 719 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The student pilot measured 1 inch of fuel in the right tank and 3 inches of fuel in the left tank using a stick during the preflight inspection. Based on fuel consumption calculations from a multi-day flight home after purchasing the airplane out of state, he determined that the fuel measurements represented 5 hours of flying time. After about 2 hours and 20 minutes of flight in the practice area and performing eight touch-and-go takeoffs and landings, all while using the left fuel tank, the engine lost total power, and the propeller continued to windmill. The flight instructor took control of the airplane but was unable to restore engine power. During the forced landing, the instructor pitched up to avoid power lines, heard the stall warning horn, and the airplane then descended to the ground and landed hard, substantially damaging the right wing. Examination of the wreckage revealed no evidence of fuel in the left tank, fuel lines, gascolator, or fuel pump. The right fuel tank contained about 1 inch of fuel. No other preimpact anomalies or malfunctions that would have precluded normal operation were observed; therefore, it is likely that the engine lost power when the fuel in the left tank was exhausted. The pilots’ previous calculation of the airplane’s fuel burn rate during a previous cross-country flight did not take into consideration prolonged flight without leaning the mixture or the multiple landings on the accident flight. The flight instructor stated that neither he nor the student performed the appropriate preflight fuel planning.

Factual narrative

On October 27, 2021, at 1750 eastern daylight time, a Beech BE-23 airplane, N2353Z, was substantially damaged when it was involved in an accident near Ballston Spa, New York. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student pilot checked the fuel levels during the preflight inspection, measuring 1 inch of fuel in the right tank and 3 inches of fuel in the left tank with a ruler. Based on his calculations of the airplane’s fuel consumption during the 3-day, multi-leg flight home from Texas after purchasing the airplane, he determined that each inch represented 1 hour and 15 minutes of flying, and therefore they had 5 hours of flying time. The student and instructor departed Saratoga County Airport (5B2), Saratoga Springs, Florida, around 1530. They flew in the practice area then around a nearby lake before returning to 5B2, where they completed eight touch-and-go takeoffs and landings. About 2 hours and 20 minutes into their flight, after turning to final approach on the ninth landing, the engine sputtered, stopped producing power, and the propeller continued to windmill. The instructor took control of the airplane, established the best glide speed, and performed a quick check of the mixture, carburetor heat, ignition, and master switches, but was unable to restore engine power. He selected an area for a forced landing and as the airplane descended, he noted power lines in their flightpath. He pitched the airplane up to avoid power lines and heard the stall horn sound. The airplane missed the power lines, descended to the ground, and landed hard, fracturing the nose landing gear. The airplane then nosed over and slid to a stop. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest upright in a nose-down attitude. The right wing was substantially damaged where the right main landing gear pushed up into the wing. There was no evidence of fuel in the left-wing tank and the right-wing tank was about 1/8 full. The flight instructor stated that they used fuel solely from the left tank, did not switch fuel tanks during the flight, and leaned the mixture during the cruise portions of the flight. Postaccident examination of the airplane revealed that the left fuel tank gauge needle indicated “E” and the right fuel tank gauge needle indicated just above “E” when the airplane’s electrical master switch was selected ON. Both right and left fuel caps were secure and the fuel vents were unobstructed. No fuel was present in the left tank, and about 1 inch of fuel was present in the right tank. All fuel lines from the left and right fuel tanks to the fuel selector, gascolator, both fuel pumps and the carburetor were intact and devoid of fuel. No fuel was found in the gascolator bowl or the electric fuel pump. The examination revealed no other preimpact anomalies or malfunctionsthat would have precluded normal operation. The airplane’s pilot’s operating handbook (POH) stated, “do not take off when the Fuel Quantity Gages indicate in the yellow band or with less than 11 gallons in each main tank.” A cockpit placard specified a capacity of 26 gallons for the left fuel tank and 26 gallons for the right fuel tank; however, the student reported that the airplane’s tanks held 60 total gallons of fuel. In follow-up interviews with the flight instructor and student about fuel planning, the student indicated that they were leaning the fuel mixture and had a tailwind when returning home from Texas and calculating the airplane’s fuel consumption rate. Both indicated that the fuel measured 9 inches when full. When asked about the fuel planning performed before the accident flight, the instructor responded, “Neither of us did and that's the problem.”

Aircraft

Registration
N2353Z
Reported as
Beech 23
Category
Airplane
Serial number
1963
Built
1965
Airframe hours
2,304.8
Engine
Lycoming O-320-D2B, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2021 · 28.9 hours before
Departed
5B2 · Saratoga Springs, NY
Airport
5B2 · Saratoga County
Equipment
None

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
35
Injuries
None
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 12, 2021
Seat
Right
Restraint
Lap only
Flight hours
6,085 total · 20 in this make and model · 2,925 as pilot in command · 141 in the last 90 days · 38 in the last 30 days · 0 in the last 24 hours
Role
Student pilot
Age
30
Injuries
None
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
28 total · 20 in this make and model · 0 as pilot in command · 27 in the last 90 days · 3 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 9 knots
Visibility
10 statute miles
Lowest ceiling
7,500 ft broken
Temperature
52 °F, dew point 39 °F
Altimeter
29.89 inHg
Turbulence
Unknown
Observed at
SCH, 12 nm away
METAR
KSCH 272151Z 04009KT 10SM SCT050 BKN075 11/04 A2989

Docket · 8

The files NTSB released with the investigation on August 30, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.