# NTSB IAD02LA035: Beechcraft C23, N2192W, Wilmington, DE, February 25, 2002 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 25, 2002, 18:55 local (23:55 UTC) - Place: Wilmington, DE - Coordinates: 39.760948, -75.53009 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7609&lon=-75.5301&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report August 26, 2003 - Report: Approved by Office Director - NTSB case key (mKey): 54254 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD02LA035 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54254/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54254 - Page: https://openairdocs.org/ntsb/IAD02LA035 ## Probable cause the flight instructor's improper fuel management which resulted in fuel starvation. A factor in the accident was the flight instructor's failure to follow the published checklist procedures. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, circling (ifr) - fluid,fuel - starvation (cause) - fuel management - improper, pilot in command(cfi) (cause) - checklist - not followed, pilot in command(cfi) (contributing factor) - Forced landing, descent - emergency - In flight collision with terrain/water, emergency landing - terrain condition - drop-off/descending embankment ## Analysis The flight instructor and private pilot were returning to their home airport after a 1.9 hour instructional flight. On final approach, the engine stopped producing power. The flight instructor took control of the airplane and landed on an embankment short of the runway. According to a police officer, who arrived on the scene an hour after the accident, the left fuel tank was found empty, and the fuel selector valve was found positioned to the left tank. The tank was not breached and there were no signs of leakage. However, fuel was observed in the right fuel tank. When the fuel selector valve was positioned to the right fuel tank, fuel flowed freely from the fuel strainer fuel line. Eighteen gallons of fuel were then drained from the right fuel tank. According to the Beechcraft Sundowner C23 Pilot's Operating Handbook (POH), the fuel selector handle was located on the floorboards between the pilot and copilot seats. According to the published before landing checklist, item 2 stated: "Fuel Selector Valve-SELECT TANK MORE NEARLY FULL (feel for detent and check visually)." No mechanical deficiencies were noted with the engine, or fuel system. ## Factual narrative On February 25, 2002, at 1855 eastern standard time, a Beechcraft C23, N2192W, was substantially damaged after it experienced a total loss of engine power while on final approach to runway 19 at New Castle County Airport (ILG), Wilmington, Delaware. The certified flight instructor and private pilot were seriously injured. An instrument flight rules flight plan was filed for the flight that originated at ILG about 1600. Visual meteorological conditions prevailed for the instructional flight conducted under 14 CFR Part 91. In a written statement, the flight instructor said: "After shooting various instrument approaches we returned to shoot the ILS on Runway 1 Circle to Land Runway 19 after the ILS was completed. At some point during the circle the engine stopped....Upon realizing a loss of power, I took the controls from [private pilot]....I quickly began the engine failure checklist flow but was unable to finish due to being on short final and limited altitude." A sergeant with the Delaware River and Bay Authority Police Department interviewed both pilots on the evening of the accident. According to the sergeant's written report, both pilots reported that the engine stopped producing power on final approach to runway 19. The flight instructor said that he took control of the airplane, and tried to flare the airplane to get over a fence. He said the airplane landed hard, in a flat attitude, on an embankment short of the runway. The sergeant reported that there was an approximately 100-foot-deep embankment that dropped off from the approach end of runway 19. The sergeant arrived at the accident site at 2000. According to his written report, examination of the fuel tanks revealed that the right fuel tank was filled with approximately 3 1/2 inches of fuel from the bottom of the tank. The left fuel tank was "dry", and the fuel selector switch was positioned to the left fuel tank. He visually inspected the airplane's fuel tanks and observed no damage or leakage. A Federal Aviation Administration (FAA) inspector examined the engine and fuel system on February 26, 2002. According to the inspector, examination of the fuel strainer revealed that there was a small amount of fuel in the bowl, and that the fuel screen was absent of debris. The inspector then placed the fuel selector to the right tank, and observed fuel flowing freely through the fuel strainer fuel line. The inspector also removed the carburetor screen and found it to be absent of debris. Eighteen gallons of fuel were then drained from the right tank. The inspector said that compression was established on each cylinder by manual rotation of the propeller. No mechanical deficiencies were noted with the engine or fuel system. According to fuel receipts provided by the operator, the airplane was last fueled on February 24, 2002. At that time, the airplane was topped off with fuel. Examination of airplane records provided by the operator revealed that the airplane had been flown twice on the day of the accident. The first flight began at a Hobbs meter time of 1019.3, and ended at 1019.9. The next flight was the accident flight, which departed at a Hobbs meter time of 1019.9. At the accident site, the Hobbs meter read 1021.8. According to the Beechcraft Sundowner C23 Pilot Operating Handbook (POH), page 1-10, each wing fuel tank had a 29.9 gallon capacity, of which 26 gallons were usable. Examination of the POH also revealed that the fuel selector handle was located on the floorboards between the pilot and copilot seats. According to the published before landing checklist, item 2 stated: "Fuel Selector Valve-SELECT TANK MORE NEARLY FULL (feel for detent and check visually)." The pilot reported a total of 471 flight hours, of which 80 hours were in make and model. He also reported that there were no mechanical deficiencies. The private pilot reported a total of approximately 100 flight hours. Weather at New Castle County Airport, at 1851, included wind from 160 degrees at 7 knots and clear skies. ## Aircraft - Registration: [N2192W](https://openairdocs.org/deregistered/N2192W-2009-07-24), registration cancelled 2009-07-24, S/N M1564 (OpenAirDocs) - Reported make and model: Beechcraft C23 - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Category: Airplane - Serial number: M1564 - Airframe hours: 2623.3 - Engines: Avco Lycoming O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Sky Safety, doing business as Fixed Base Operator - Registered owner: Bruce And Jodi Hudson - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 21, 2001, 100.4 hours before - Departed: ILG, WILMINGTON, DE - Flight plan: IFR - Airport: ILG, New Castle County, runway 19, 7,000 × 200 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 23; injuries: serious; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review April 10, 2001; seat: right; flight hours: 471 total, 80 in this make and model, 355 as pilot in command, 117 in the last 90 days, 61 in the last 30 days, 5 in the last 24 hours - Pilot; age 20; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 100 total ## Weather - Conditions: Visual (VMC), Night - Wind: 160° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 45 °F, dew point 45 °F - Altimeter: 30.09 inHg - Observed at: ILG ## 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 20020225037889A](https://openairdocs.org/incident/20020225037889A), Feb 25, 2002: Beech C23, Wilmington, DE, Substantial damage. (-23) Aircraft reported engine failure on short final at ilg airport. Investigation showed fuel selector selecting left fuel tank. Fuel quantity in left tank… ## Docket (5 files) The files NTSB released with the investigation on June 24, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54254. 814 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 1, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390161&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Redacted.PDF - FAA Inspector Statement (item 2, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40179903&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Police Department Report (item 3, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40179904&FileExtension=.PDF&FileName=Police%20Department%20Report-Master.PDF - Fuel Log and Receipt (item 4, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390162&FileExtension=.PDF&FileName=Fuel%20Log%20and%20Receipt-Redacted.PDF - POH (item 5, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40179906&FileExtension=.PDF&FileName=POH-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.