# NTSB ERA22LA033: Beech 23, N2353Z, Ballston Spa, NY, October 27, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 27, 2021, 17:50 local (21:50 UTC) - Place: Ballston Spa, NY - Coordinates: 43.042795, -73.871071 - Nearby events: https://openairdocs.org/map.md?lat=43.0428&lon=-73.8711&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 104171 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104171/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104171 - Page: https://openairdocs.org/ntsb/ERA22LA033 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Beech 23, 3 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151202), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech 23, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151202), [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 · Student/instructed pilot (probable cause); cases with it: [Beech 23, 3 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151202), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/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 starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech 23, 3 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151202), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech 23, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151202), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach-VFR pattern final: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech 23, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151202), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Approach: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Beech 23, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=1151202), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Approach: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Beech 23, 2 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=1151202), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## 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](https://openairdocs.org/deregistered/N2353Z-2023-10-07), registration cancelled 2023-10-07, S/N M-67 (OpenAirDocs) - Reported make and model: BEECH 23 - Registry model: [Beech 23](https://openairdocs.org/model/beech-23) (registry code 1151202) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1963 - Year built: 1965 - Airframe hours: 2304.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 35; injuries: none; 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 - Student pilot; age 30; injuries: none; 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 ## 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 20211027020779A](https://openairdocs.org/incident/20211027020779A), Oct 27, 2021: Beech 23, Saratoga, NY, Substantial damage. Instructor and student departed on local flight. Utilized homemade dipstick to verify 3 inches in left wing, 1 inch in right. Declined onboarding fuel prior to… ## Docket (8 files) The files NTSB released with the investigation on August 30, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104171. 11.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13411567&FileExtension=pdf&FileName=ERA22LA033%206120%20Signed_Redacted-Rel.pdf - Pilot statements (item 2, PDF, 6 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13459181&FileExtension=pdf&FileName=Instructor%20and%20Student%20Statements_Redacted-Rel.pdf - NTSB record of conversation - FAA inspector statements (item 3, PDF, 1 page, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13413700&FileExtension=pdf&FileName=ERA22LA033%20ASI%20Statements-Rel.pdf - POH excerpts (item 4, PDF, 3 pages, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13413442&FileExtension=pdf&FileName=Excerpts%20from%20POH-Rel.pdf - Weather reports and carburetor icing probability chart (item 5, PDF, 2 pages, 941 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13458937&FileExtension=pdf&FileName=Weather%20Reports%20and%20Carburetor%20Icing%20Probability%20Chart-Rel.pdf - Investigative photographs (item 6, PDF, 9 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13414585&FileExtension=pdf&FileName=ERA22LA033%20Photo%20Array-Rel.pdf - Airplane examination summary (item 7, PDF, 3 pages, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13413064&FileExtension=pdf&FileName=N2353Z%20NTSB%20Inspection%20-%2011-22-2021_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13413074&FileExtension=pdf&FileName=ERA22LA033%20Signed%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.