# NTSB FTW95LA128: Beech 58P, N208DK, Montrose, CO, March 1, 1995 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 1, 1995, 10:40 local (17:40 UTC) - Place: Montrose, CO - Coordinates: 38.490554, -107.870758 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.4906&lon=-107.8708&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report June 22, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 19362 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95LA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19362/pdf - Page: https://openairdocs.org/ntsb/FTW95LA128 ## Probable cause THE PILOT'S FAILURE TO REFUEL THE AIRPLANE RESULTING IN A FORCED LANDING. THE ADVERSE WEATHER CONDITIONS WERE FACTORS. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, approach - faf/outer marker to threshold (ifr) - weather condition - below approach/landing minimums (contributing factor) - weather condition - obscuration (contributing factor) - Forced landing, approach - refueling - not performed, pilot in command (cause) - Nose over, landing - flare/touchdown - terrain condition - soft ## Analysis ACCORDING TO THE PILOT, VISUAL METEOROLOGICAL CONDITIONS (VMC) WERE FORECAST FOR BOTH HIS DESTINATION, GUNNISON, CO AND HIS ALTERNATE, MONTROSE, CO. DURING FLIGHT HE DETERMINED THAT THE HEAD WINDS WERE STRONGER THAN FORECAST RESULTING IN INCREASED FUEL USAGE. HE DECIDED TO CONTINUE TO GUNNISON BASED ON INFLIGHT INFORMATION GIVEN TO HIM THAT VMC PREVAILED. ARRIVING IN GUNNISON, INSTRUMENT METEOROLOGICAL CONDITIONS (IMC) EXISTED, AND THE PILOT MADE AN ILS APPROACH. THE APPROACH WAS MISSED AND HE DIVERTED TO HIS ALTERNATE, MONTROSE. EN ROUTE THE PILOT ADVISED ATC HE WAS LOW ON FUEL. HE CROSSFED THE LEFT ENGINE FROM THE RIGHT FUEL TANK BECAUSE THE LEFT TANK WAS EMPTY. THE PILOT MADE AN ILS APPROACH TO MONTROSE. AT DECISION HEIGHT, THE RUNWAY ENVIRONMENT WAS NOT IN SIGHT. BECAUSE OF THE CRITICAL FUEL STATE, POOR WEATHER CONDITIONS, AND SURROUNDING HIGH TERRAIN, THE PILOT ELECTED TO LAND IN A FIELD HE HAD SIGHTED. THE AIRPLANE TOUCHED DOWN IN MUD AND NOSED OVER. OCCASIONAL IFR CONDITIONS AND MOUNTAIN OBSCURATION FOR THE ACCIDENT VICINITY WERE FORECAST IN PERTINENT AIRMETS PRIOR TO AND DURING THE FLIGHT. ## Factual narrative On March 1, 1995, at approximately 1040 mountain standard time (all times are mountain standard time unless otherwise noted), a Beech 58P, N208DK, was destroyed when it impacted terrain during a landing approach at Montrose, Colorado. The private pilot-in- command and commercial rated pilot/passenger were seriously injured. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan had been filed. The business flight, conducted under Title 14, Code of Federal Regulations, Part 91, originated at Fort Worth, Texas, at 0600. The following is based on written pilot statements submitted along with the pilot/operator report. The pilot and his passenger obtained several independent weather briefings and filed an IFR plan and departed Fort Worth, Texas. Visual meteorological conditions were forecasted for both Gunnison and Montrose, Colorado, their destination and alternate, respectively. The pilot stated that while en route, it was determined that head winds had become stronger than forecasted; resulting in increased fuel consumption. The pilot made the decision to continue to Gunnison. He based this decision on inflight information given to him "in general terms"of the prevailing visual meteorological conditions that reportedly existed at his destination. Upon arriving in the Gunnison area, the sky was obscured and it was snowing. The pilot executed an instrument landing system approach to runway 6. At decision height, the pilot made a missed approach because he was unable to visually acquire the runway environment. It was determined that sufficient fuel remained to divert to his alternate airport, 45 miles to the west. En route, to Montrose, however, the pilot advised Denver Air Route Traffic Control Center (ARTCC) that he was low on fuel. He was forced to crossfeed the left engine from the right fuel tank because the left tank was empty. An ILS approach was executed to runway 17 at Montrose and at decision height, the runway environment was not in sight. Aware of his fuel state, the poor weather conditions, and surrounding high terrain, the pilot elected to land the airplane in a field. The airplane touched down in mud and nosed over And came to rerst 1/4 mile east-northeast of runway 17. As of the writing of this report, the air traffic report requested has not been recieved. ## Aircraft - Registration: [N208DK](https://openairdocs.org/deregistered/N208DK-2015-05-06), registration cancelled 2015-05-06, S/N TJ-201, built 1979 (OpenAirDocs) - Reported make and model: BEECH 58P - Registry model: [Beech 58P](https://openairdocs.org/model/beech-58p) (registry code 1152744) (OpenAirDocs) - Category: Airplane - Serial number: TJ-201 - Airframe hours: 2100 - Engines: CONTINENTAL TSIO-520-WB 325 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: Bhem, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 15, 1995, 50 hours before - Departed: FTW, FORT WORTH, TX - Flight plan: IFR - Airport: MTJ, Montrose County Municipal, runway 17, 10,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 4,360 total, 450 in this make and model, 4,150 as pilot in command, 61 in the last 90 days, 35 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 330° at 10 knots - Visibility: 1.75 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 34 °F, dew point 34 °F - Altimeter: 29.00 inHg - Observed at: MTJ ## 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 19950301002889A](https://openairdocs.org/incident/19950301002889A), Mar 1, 1995: Beech 58P, Montrose, CO, Destroyed. Unable destination due weather. Diverted, unable see runway. Low fuel elected land beyond runway. Nosed over. 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.