FTW95FA101

NTSB accident investigation · Beech A36 · Wallisville, TX · January 26, 1995

Accident · FatalField investigationFinal report
Date
January 25, 1995, 21:40 local (Jan 26, 1995, 03:40 UTC)
Place
Wallisville, TX
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N7250UBeech A36
Weather
Visual (VMC) · Night/dark
Status
Completed · report June 13, 1996
Report
Approved by Office Director
FAA report
19950125000769A
Case key
19206

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

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Probable cause

Fuel starvation due to improper positioning of the fuel tank selector, which resulted in loss of engine power. Factors related to the accident were: darkness and a lack of suitable terrain for the forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalCruise
Fluid,fuel - starvationCause
Fuel tank selector position - improperPilot in commandCause
Use of inappropriate medication/drugPilot in command
Forced landingDescent - emergency
In flight collision with objectEmergency landing
Light condition - nightFactor
Terrain condition - none suitableFactor
Object - tree(s)
In flight collision with terrain/waterEmergency landing
Terrain condition - water

Analysis

While en route from destin, FL, to houston, TX, the passenger noted that the pilot periodically switched fuel tanks. Also, he noted beeping sounds that stopped after the autopilot was turned off and the automatic (pitch) trim circuit breaker was pulled. During darkness, as the flight approached anahuac, TX, the engine lost power. The pilot restarted the engine, but seconds later, it lost power again and would not restart. During an emergency landing, the airplane collided with trees and came to rest partially submerged in water. The fuel tank selector was found positioned between the left and right tank. Engine test runs were successful. A toxicology test of the pilot's blood showed 0.583 mcg/ml fluoxetine (prozac) and 0.254 mcg/ml norfluoxetine (metabolite of fluoxetine). A test of his urine showed 0.344 mcg/ml fluoxetine and 0.195 mcg/ml norfluoxetine. The prescription drug, prozac, is an antidepressant and is not approved for use while flying.

Factual narrative

History of flight:

On January 25, 1995, at 2140 central standard time, a Beech A36, N725OU, was destroyed during a forced landing near Wallisville, Texas. The private pilot sustained fatal injuries and the passenger was seriously injured. Visual meteorological conditions prevailed for the business cross country flight.

During an interview and on the enclosed statement, the passenger reported the information in this paragraph. At 1810, when the pilot and passenger arrived at the Destin, Florida, airport, the pilot obtained fuel and performed a preflight inspection of the airplane. Prior to departure and during the flight, the aft door warning light and the cockpit door light were illuminated; however, the pilot indicated that the doors were secure. The pilot and passenger used oxygen (a procedure used by the pilot for night flights) from a portable bottle. Initial cruise flight was at 6,000 feet MSL and en route the airplane descended due to lowering ceilings.

During the interview, the passenger further reported that he recalled the following events; "the sequence of events and the location of occurrence was not clear." In the vicinity of Beaumont, Texas, one fuel tank gauge was reading higher than the other gauge, and the pilot said that he was switching back and forth between the two tanks. About 10 minutes before impact, the passenger noted the fuel gauges showing between 1/3 and 1/2 full. As the flight approached Beaumont, Texas, a repetitive "beep" was heard in the cockpit and the pilot replied that the autopilot was not working and he would fly the airplane manually.

The beeping stopped when the pilot turned off the autopilot; however, after the flight passed over Beaumont, a panel warning light illuminated and a buzzer (continuous beep) for the automatic trim (autopilot pitch trim) was heard. Circuit breakers were checked, and at the request of the pilot, the passenger pulled the automatic (pitch) trim circuit breaker. Subsequently the warning light went out and the buzzer silenced. The pilot radioed an air traffic controller about the electrical problem; however, the pilot did not declare an emergency.

As the flight approached Anahuac, Texas, a total loss of engine power occurred and the pilot restarted the engine. Within seconds, a total loss of engine power again occurred. The pilot declared an emergency and requested vectors to an airport. The passenger recalled seeing trees illuminated by the airplane lights.

The airplane was found with the cockpit and cabin areas submerged in Lake Miller. Rescue personnel reported that, during their initial arrival, flames from the fire surrounded the airplane. Local authorities reported the passenger exited the cockpit and was rescued by helicopter. Light drizzle was reported throughout the area during the rescue.

Personnel information:

A review of the pilot's logbook revealed a high performance endorsement dated October 7, 1991, for the A36. The last night flight was 0.6 hour logged on November 14, 1992. The pilot's only logged time since November 1992 was 6.8 hours of dual instruction (biennial flight review and instrument competency check), from October 24, 1994, through November 1, 1994.

The pilot's third class Federal Aviation Administration (FAA) medical certificate application dated January 6, 1994, showed a total flight time of 500 hours and 40 hours of flight time in the previous 6 months. Acquaintances of the pilot reported that the pilot had several hundred hours of flight time which had not been logged.

Aircraft information:

Maintenance records recovered from the submerged airplane were reviewed. On May 2, 1991, the alternator regulator was replaced and adjusted. Date of issuance of the registration certification to the current owner/operator was January 31, 1992. At a total airframe time of 639.0 hours, the factory remanufactured engine was installed on August 14, 1992. On November 9, 1993, the fuel pump coupling was replaced and the pump was sent to the factory for flow check and adjustment prior to reinstallment on the engine. On October 14, 1994, the fuel pump was removed due to a lack of fuel pressure at low RPM's and the pump was reinstalled after a satisfactory bench check.

Communication:

A review of air traffic control data (enclosed) revealed the following summary information. All times are converted to central standard time unless otherwise indicated.

At 2115:42 Beaumont approach was advised of the descent to 4,500 feet MSL. At 2132:09 the pilot radioed Beaumont Approach Control and advised that he was "having a slight electrical problem" but did not want to declare an emergency. The flight was given a transponder code of 1074 and Houston Air Route Traffic Control (ARTCC) was advised of the information from N7250U. Houston ARTCC assigned a transponder code of 0232 at 2134, cleared the flight into Class B airspace, and assigned a heading of 250 degrees for vectors to the planned destination.

The pilot declared an emergency at 2137:25 and requested the nearest airport. At 2137:42 the pilot reported a loss of engine power and requested vectors to the nearest lighted airport. At 2139:05 an engine restart was reported followed by a negative at 2139:14. The controller continued vectors to an airport; however, at 2139:45 the pilot transmitted "we're going to try the freeway" and at 2139:52 the pilot responded "affirmative" to an inquiry from the controller about again loosing engine power. That was the last recorded radio transmission.

Wreckage and impact information:

The impact site was approximately 1 mile north of Interstate 10 at a longitude of 94 degrees 44.05 minutes north and longitude 29 degrees 51.12 minutes west. The right outboard wing, left horizontal stabilizer, and left wing were separated from the airframe. Post impact fire damage was noted on the inboard right wing section and the cabin door. The airplane came to rest on a measured magnetic heading of 170 degrees with the fuselage and cabin area submerged. See the enclosed diagram for additional details.

Cockpit examination revealed the pitch trim circuit breaker tripped and the fuel selector positioned between the left and right tank. Divers reported that fuel contamination in the water hampered the recovery of the left wing.

Medical and pathological information:

The autopsy was performed by the Office of the Medical Examiner of Harris County Joseph A. Jachimczyk Forensic Center at Houston, Texas. According to Dr. Canfield, of the Federal Aviation Administration Civil Aeromedical Institute at Oklahoma City, Oklahoma, the "concentrations of 0.583 (ug/mL, ug/g) Fluoxetine (Prozac) detected in blood, 0.254 (ug/mL, ug/g) Norfluoxetine (metabolite of Prozac) detected in blood, 0.344 (ug/mL, ug/g) Fluoxetine detected in urine, and 0.195 (ug/mL, ug/g) Norfluoxetine detected in urine, may cause impairment." According to Dr. Salazar, FAA Southwest Regional Flight Surgeon, is not listed as an authorized medication by the FAA "because it may cause impairment."

Test and research:

The engine driven fuel pump and engine were preserved for an engine run. No fuel was found in the fuel lines when the fuel pump was removed. The pump drive coupling was intact and the pump rotated by hand. Flight control continuity was confirmed. Fuel screens contained debris and the left fuel tank adjacent to the fuel return line and vent line contained an unidentified material; however, all vent lines were pressure checked with no blockage found. Propeller blades exhibited scrapes and bending.

The engine driven fuel pump was installed and all fuel screens replaced prior to the engine runs. With fuel being supplied through the left tank plumbing and left fuel selector position the first run (10 minutes) was conducted at 1,000 RPM's. A test fuel flow gauge and manifold pressure gauge were hooked into the system and th

Aircraft

Registration
N7250U
Reported as
Beech A36
Category
Airplane
Serial number
E2276
Airframe hours
910
Engine
Continental IO-550-B, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Business · Part 91
Registered owner
Scott H. Deberry
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 5, 1994 · 22 hours before
Departed
81J · Destin, FL
Destination
IWS · Houston, TX

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
341 total · 152 in this make and model · 286 as pilot in command · 7 in the last 90 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
110° at 9 knots
Visibility
15 statute miles
Lowest ceiling
3,500 ft overcast
Temperature
61 °F, dew point 55 °F
Altimeter
30.00 inHg
Observed at
HOU, 35 nm away

Docket · 17

The files NTSB released with the investigation on October 1, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.2 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.