# NTSB FTW03FA067: Beech F-35, N3367C, Addison, TX, December 28, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 28, 2002, 11:55 local (17:55 UTC) - Place: Addison, TX - Coordinates: 32.953887, -96.809722 - Nearby events: https://openairdocs.org/map.md?lat=32.9539&lon=-96.8097&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 30, 2004 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Federal Aviation Administartion (FSDO) - NTSB case key (mKey): 56250 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW03FA067 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56250/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56250 - Page: https://openairdocs.org/ntsb/FTW03FA067 ## Probable cause The pilot's mismanagement of the fuel supply by his failure to switch fuel tank positions which resulted in fuel starvation and the loss of engine power. A contributing factor was the lack of suitable terrain for the forced landing. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - fuel management - inadequate, pilot in command (cause) - fluid,fuel - starvation (cause) - fuel tank selector position - inadequate, pilot in command (cause) - Forced landing, descent - emergency - In flight collision with terrain/water, emergency landing after takeoff - terrain condition - none suitable (contributing factor) - terrain condition - ground ## Analysis The airplane impacted trees and terrain during a forced landing after takeoff from Runway 15. According to witnesses, the airplane was traveling toward the east, at a "very low altitude," and parallel to Beltline Road. Two witnesses reported that the airplane appeared to be gliding and they could not hear the sound of the engine. The witnesses also stated that they were unable to determine if the propeller was rotating. The aircraft impacted trees and terrain with the landing gear and flaps in the retracted position. There was no post-impact fire. The airplane was last refueled on December 20, 2002 with 24.8 gallons of 100LL fuel. Examination of the right fuel system revealed that there was three gallons of fuel in the tip tanks, and twelve gallons of fuel in the auxiliary fuel tank. The left main fuel cell was breached. The fuel selector was found in the right main tank position. Flight control continuity was established. No anomalies were found with the airframe at the accident site. The engine was successfully ran to full power. ## Factual narrative HISTORY OF FLIGHT On December 28, 2002, at 1155 central standard time, a Beech F-35 single-engine airplane, N3367C, was destroyed during a forced landing following a loss of engine power after takeoff from the Addison Airport (ADS), near Addison, Texas. The airplane was owned and operated by the pilot. The private pilot, sole occupant of the airplane, sustained fatal injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The local flight was originating at the time of the accident. Personnel from the air traffic control tower (ATCT) at ADS, stated that the flight was cleared to takeoff from Runway 15 at 1146. The ATCT received a call from the Addison Police Department with notification of an airplane accident near the intersection of Beltline Road and Winwood Road, minutes after the aircraft had departed. According to witnesses, the airplane was traveling toward the east, at a "very low altitude," and parallel to Beltline Road. Two witnesses reported that the airplane appeared to be gliding and they could not hear the sound of the engine. The witnesses also stated that they were unable to determine if the propeller was rotating. Subsequently, the airplane descended behind trees and out of the witnesses field of view. PERSONNEL INFORMATION The pilot held a private pilot certificate, issued on August 15, 1989, with a single-engine land rating. On the pilot's last application for a Federal Aviation Administration (FAA) medical certificate, which was dated January 31, 2002, he reported that he had accumulated a total of 2,300 flight hours, of which 50 hours were in the last six months. He held a third-class medical certificate with two limitations. The first limitation required the pilot to wear corrective lenses for near and distant vision and the second stated "not valid for any class after January 31, 2003." AIRCRAFT INFORMATION The 1955-model airplane, serial number D-4034, was registered to the pilot/owner on February 6, 1990. On August 30, 2002, the last annual inspection was completed, at which time the airplane had accumulated a total airframe time of 6,258.1 hours, tachometer time of 1,582.8. At the time of the accident the airplane had accumulated a total airframe time of 6,329.8 hours, tachometer time of 1,654.5. The airplane was powered by a 260-horsepower Continental IO-470-N11B engine, serial number 458172. The engine was manufactured on July 4, 1999, and installed on the airplane on August 2, 1999. On December 27, 2002, at a total engine tachometer time of 1,653.8 hours, a new ignition kit, which consisted of two new magnetos, a new harness, and 12 new spark plugs, was installed in the airplane. The engine was ground run and no anomalies were noted. According to the mechanic who installed the kit, the pilot requested that the kit be installed due to a vibration. A two-bladed McCauley model 2A36C23-P-CE6 propeller assembly (Hub serial number 713597 and blade numbers HF005YS and HF014VS) received an annual inspection on August 30, 2002. The airplane was last refueled on December 20, 2002, with 24.8 gallons of 100LL fuel by Mercury Aviation at ADS. METEOROLOGICAL INFORMATION The Automated Surface Observing Station ADS, at 1147, reported winds from 190 degrees at 5 knots, visibility 13 statute miles, clear skies, temperature 16 degrees Celsius, dew point 3 degrees Celsius, and an altimeter setting of 30.31 inches of Mercury. The Investigator-In-Charge (IIC) calculated the density altitude to be approximately 554 feet. WRECKAGE AND IMPACT INFORMATION The airplane came to rest upright in a moderately wooded area, adjacent to Beltline Road, on a measured magnetic heading of 120 degrees. The Ground Positioning System (GPS) location of the accident site was 32 degrees 57 minutes 24 seconds North latitude, and 096 degrees 48 minutes and 58 seconds West longitude. The initial impact point was 46 feet from the wreckage. Located at the initial impact point was the outboard section of the right wing and aileron. The ruddervator and inboard section of the right wing were located 32 feet from the wreckage. The fuselage, left wing, cockpit, engine, and propeller remained attached to each other. There was no post-impact fire. The propeller blades did not display chordwise scratching; the blades' leading edges were clean, and the propeller spinner did not display rotational damage. One of the propeller blades was bent aft at mid-span. The cockpit was examined. The fuel selector was found in the right tank position and the auxiliary boost pump was in the OFF position. The throttle and mixture were observed in the full-forward position. The flap selector was in the UP position, the landing gear selector was in the retracted position. The autopilot switch was OFF and the emergency air switch was CLOSED. Flight control continuity was established from the cockpit to the left aileron; however continuity was not possible to the right aileron as a result of the right wing separating. All cable separations examined displayed frayed, uneven ends consistent with overstress. Flight control continuity for the rudder, elevator and elevator trim was established from the cockpit to the point at which the tail separated from the airplane; continuity past this point was not possible as a result of the tail separating. However, all cable separation examined displayed frayed, uneven ends consistent with overstress. The engine was examined and there were no signs of catastrophic failure. The propeller was rotated and continuity was established from the propeller, through the crankshaft, to the air conditioning drive belt. Theleft main fuel cell was breached. Approximately three gallons of fuel was found in the tip tanks, and twelve gallons of fuel was found in the auxiliary fuel tank. The oil dipstick was removed and indicated 7 quarts of oil, which is within the full range. The only anomaly noted was that an air line was disconnected from the vacuum pump, as a result of the impact. The engine was transported to Lancaster, Texas, for further examination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Southwestern Institute of Forensic Sciences, Dallas, Texas, on December 29, 2002. The pilot's death was a result of multiple blunt force injuries. Toxicological testing were performed by the FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. Atropine and Lidocaine were detected in the pilot's blood and liver. TESTS AND RESEARCH On January 3, 2003, the engine was examined at Air Salvage of Dallas, Lancaster, Texas. The fuel sump beneath the low point fuel strainer was drained. The fuel sample from the sump was clear and free of contaminants. The fuel strainer, which was positioned beneath the fuel selector was removed. The fuel strainer was installed improperly (upside down), so that fuel moving through the selector did not pass through the fuel strainer screen, therefore allowing unfiltered fuel to reach the fuel pump. The fuel pump was removed, indexed, and disassembled. The fuel pump did not exhibit any debris and its gears did not appear worn. The fuel pump's drive coupling was intact and its two relief valves were not obstructed by any debris. The fuel pump was reassembled and reinstalled on the engine. The top spark plugs were removed. The number 1,2,4, and 6 cylinder spark plug electrodes were extremely light in color, consistent with a lean mixture. The number 3 and 5 cylinder spark plug electrodes contained light carbon deposits. The propeller was rotated and "thumb compression" was established for each cylinder and the impulse couplings from the magnetos were heard clicking. The top spark plugs were then reinstalled in the engine. The throttle, propeller, and mixture control were manipulated by ## Aircraft - Registration: [N3367C](https://openairdocs.org/deregistered/N3367C-2013-04-22), registration cancelled 2013-04-22, S/N D-4034, built 1955 (OpenAirDocs) - Reported make and model: Beech F-35 - Registry model: [Beech F35](https://openairdocs.org/model/beech-f35) (registry code 1151514) (OpenAirDocs) - Registry engine: [Continental E225 series](https://openairdocs.org/engine/continental-e225-series) (registry code 17015, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-4034 - Airframe hours: 6329.8 - Engines: Continental IO-470-N11B 260 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Marvin Arthur Jones - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 30, 2002, 71.7 hours before - Departed: ADS, Addison, TX ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 83; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 2,300 total ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 5 knots - Visibility: 13 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 37 °F - Altimeter: 30.30 inHg - Observed at: ADS, 2 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 20021228034139A](https://openairdocs.org/incident/20021228034139A), Dec 28, 2002: Beech F35, Addison, TX, Destroyed, 1 fatal. (-23) Aircraft departed ADS to the south at 1146. The pilot informed the ADS tower that he was headed eastward VFR. At 1148 the ADS tower received a telephone… ## Docket (9 files) The files NTSB released with the investigation on April 29, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56250. 4.0 MB in all. - Witness Statements (item 1, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418663&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 2, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211227&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418661&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418664&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 5, .PDF, 333 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418662&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1 - Wreckage (item 6, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211272&FileExtension=.PDF&FileName=Photo%201%20-%20Wreckage-Master.PDF - Photo 2 - Wreckage from Left Side (item 7, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211273&FileExtension=.PDF&FileName=Photo%202%20-%20Wreckage%20from%20Left%20Side-Master.PDF - Photo 3 - Cockpit throttle and mixture control positions. (item 8, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211274&FileExtension=.PDF&FileName=Photo%203%20-%20Cockpit%20throttle%20and%20mixture%20control%20positions.-Master.PDF - Photo 4 - Front view of wreckage. (item 9, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40211275&FileExtension=.PDF&FileName=Photo%204%20-%20Front%20view%20of%20wreckage.-Master.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.