# NTSB LAX02LA117: Beech A35, N8428A, Rio Linda, CA, March 27, 2002 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 27, 2002, 07:15 local (15:15 UTC) - Place: Rio Linda, CA - Coordinates: 38.674999, -121.444442 - Nearby events: https://openairdocs.org/map.md?lat=38.6750&lon=-121.4444&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 4 serious - Status: Completed, report March 2, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Teledyne Continental Motors - NTSB case key (mKey): 54408 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02LA117 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54408/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54408 - Page: https://openairdocs.org/ntsb/LAX02LA117 ## Probable cause the loss of engine power as a result of fuel starvation due to the pilot's inadequate fuel system management and failure to follow procedures and directives in the Pilot Operating Handbook listed by the manufacturer. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - initial climb - aircraft preflight - inadequate, pilot in command (cause) - fluid,fuel - starvation (cause) - fuel management - inadequate, pilot in command (cause) - fuel tank selector position - improper, pilot in command (cause) - Forced landing, emergency landing after takeoff - In flight collision with terrain/water, emergency landing after takeoff - terrain condition - berm (contributing factor) ## Analysis The airplane landed "flat and hard" off the end of the runway then slid into a creek bed after a loss of engine power in the takeoff initial climb. Ground witnesses said the airplane achieved about 100 feet of altitude after liftoff then the engine coughed and lost power. The pilot said that he ran the engine up off the tip tanks, and after he was satisfied that the engine was running smoothly, switched to the left main tank for takeoff. After the engine coughed and quit, he switched on the electric auxiliary fuel pump and ensured that he was operating off the left main tank, but did not have time to attempt a restart. A California Highway Patrol pilot officer was the first to arrive on the accident scene and turned the tip tank fuel selector valve from the LEFT to the OFF position. Subsequent examination of the selector panel by an FAA inspector found the main fuel valve in the right main tank position; however, this was after the fire department said it's personnel had "moved several switches and levers" in order to secure the cockpit. Fuel tank documentation found that the left and right mains contained about 7.5 gallons and 5 gallons, respectively; the left tip tank was empty, and the right tip tank destroyed. There was no sign of fuel leakage on the ground below the left tip tank. The fuel supply line to the carburetor was loosened and about 1 tablespoon of fuel was recovered from the line. The Owner's Manual states several times that "in no case should a takeoff be made if the fuel indicators are in the yellow band or, with less than 10 gallons of fuel in each of the main tanks." According to Raytheon Aircraft, this warning is due to the location of the fuel pickups in the tanks on this model aircraft, which would allow unporting and fuel supply interruption with steep attitudes, turning type ground maneuvers during takeoffs, or uncoordinated flight. Following recovery of the airplane to a salvage yard, the engine was mounted on a test stand, and it started on the first attempt and accelerated smoothly with normal throttle response and magneto operation. ## Factual narrative On March 27, 2002, at 0715 Pacific standard time, a Beech A35, N8428A, collided with the ground following a loss of engine power in the takeoff initial climb from runway 17 at the Rio Linda Airport (Q94), Rio Linda, California. The pilot was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and three passengers sustained serious injuries; the airplane sustained substantial damage. The personal cross-country flight was departing Rio Linda en route to Buchanan Field Airport (CCR), Concord, California. Visual meteorological conditions prevailed, and no flight plan had been filed. Ground witnesses at the airport reported that the airplane achieved about 100 feet of altitude in the takeoff initial climb from the 2,620-foot-long runway when the engine quit. The airplane landed "flat and hard" off the end of the runway and slid into a creek bed. In an interview with the Safety Board investigator-in-charge, the pilot stated that he had been flying the same route daily for the 3 months prior to the accident, always following the same procedures. He would takeoff on the left main tank, and upon reaching his cruise altitude, would switch to the tip tanks for the duration of the flight. Initial statements by the pilot indicated that he believed to have had only 21 gallons of automotive fuel on board. Later, he stated that the 13.5-gallon capacity tip tanks were refueled the evening prior to the accident, but the main tanks were not, as he was concerned with the weight and balance of the already heavily loaded airplane. During preflight, the pilot says he sumped and checked the fuel tank levels visually, and neither found contaminants nor any unusually low fuel levels. He ran the engine up off the tip tanks, and after he was satisfied that the engine was running smoothly, switched to the left main tank for takeoff. After the engine coughed and quit, he switched on the electric auxiliary fuel pump and ensured that he was operating off the left main tank, but did not have time to attempt a restart. A Federal Aviation Administration (FAA) inspector from the Sacramento, California, Flight Standards District Office, responded to the accident site. He interviewed witnesses and performed an initial documentation of the aircraft. The fuel selector panel was set with the auxiliary selector handle in the "TIPS-OFF" position and the main selector handle selected to "RIGHT MAIN." The fuel tank documentation found that the left and right mains were filled with about 7.5 gallons and 5 gallons, respectively; the left tip tank was empty, and the right tip tank destroyed. There was no sign of fuel leakage on the ground below the left tip tank. The fuel supply line to the carburetor was loosened and about 1 tablespoon of fuel was recovered from the line. No water or contaminants were found in the automotive fuel. A review of the airplane maintenance records found a data package for Supplemental Type Certificate (STC) number SE2033CE and SA2045CE. These STCs authorize the use of automotive fuel in the Continental E-185-11 engine installed in the BE-35-A35 airframe. The FAA inspector could not find a maintenance entry or FAA Form 337 approving the airplane for return to service after the incorporation of the STCs. Two FAA 337 forms were found in the data package but neither had the "proper signatures." A California Highway Patrol Airborne Officer who was the first to arrive on the accident scene turned what he remembered to be the left tip tank fuel selector to the off position, in addition to turning off the magneto switch and battery. Under the supervision of FAA inspectors, a representative of the engine manufacturer completed a cursory examination of the engine at the accident site, and did not find any external evidence of an engine failure. The top spark plugs were pulled from cylinders 1, 3, and 5 and all exhibited lean operating signatures. The airplane was relocated to Plain Parts, Pleasant Grove, California, where an engine examination and test run took place. Teledyne Continental completed the examination on April 18, 2002, under the auspices of the FAA inspector. The engine was mounted on a test stand, and on the first attempt started and accelerated with normal throttle response. Oil pressure was normal. The Owner's Manual for the Beech A35 states several times that "in no case should a takeoff be made if the fuel indicators are in the yellow band or, with less than 10 gallons of fuel in each of the main tanks." According to an Air Safety Investigator from the Raytheon Aircraft Corp., these warnings are due to the fact that under certain flight conditions, the fuel feed could temporarily unport, interrupting the steady flow of fuel to the engine. These flight conditions include sudden steep turns, unusually steep attitudes, and prolonged uncoordinated flight. Weight and balance calculations were performed using data published by the airplane manufacturer and information provided by the pilot. The calculations were completed with and without fuel in the tip tanks. Without fuel in the tip tanks, the gross weight was 2626.9 and the center of gravity was 86.3 inches. With fuel in the tip tanks, the gross weight was 2788.9 and the center of gravity was 86.5 inches. The maximum allowable gross weight was 2,650 pounds and the aft limit of the center of gravity range was 85.4 inches. ## Aircraft - Registration: [N8428A](https://openairdocs.org/deregistered/N8428A-2004-07-09), registration cancelled 2004-07-09, S/N D-1842, built 1948 (OpenAirDocs) - Reported make and model: Beech A35 - Registry model: [Beech A35](https://openairdocs.org/model/beech-a35) (registry code 1151504) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D1842 - Airframe hours: 5070 - Engines: Continental E185-11 205 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Lyle D. Marshall - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, December 29, 2001, 100 hours before - Departed: Q94, Rio Linda, CA - Destination: CCR, Concord, CA - Airport: Q94, Rio Linda Airport, runway 17, 2,625 × 42 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 589 total, 170 in this make and model, 577 as pilot in command, 76 in the last 90 days, 25 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 45 °F, dew point 41 °F - Altimeter: 30.01 inHg - Observed at: KSMF, 10 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 20020327007989A](https://openairdocs.org/incident/20020327007989A), Mar 27, 2002: Beech A35, Rio Linda, CA, No damage. (-23) On 03/27/2002, at approximately 07:20 hours, N6428A, a Beechcraft 35-A35, serial number D-1842, departed Rio Linda Airport, CA (Q94) enroute for the… ## Docket (13 files) The files NTSB released with the investigation on December 13, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54408. 1.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398250&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Continental Letter (item 2, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398248&FileExtension=.PDF&FileName=Continental%20Letter-Redacted.PDF - Record of Conversation - Pilot (item 3, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195226&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Record of Conversation - Raytheon (item 4, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195227&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Raytheon-Master.PDF - Record of Conversation - Teledyne Continental (item 5, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195979&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Teledyne%20Continental-Master.PDF - FAA Statement (item 6, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398255&FileExtension=.PDF&FileName=FAA%20Statement-Redacted.PDF - POH Excerpts for Beechcraft Bonanza 35 (item 7, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195975&FileExtension=.PDF&FileName=POH%20Excerpts%20for%20Beechcraft%20Bonanza%2035-Master.PDF - Teledyne Continental Report (item 8, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195976&FileExtension=.PDF&FileName=Teledyne%20Continental%20Report-Master.PDF - Weight and Balance Calculations (item 9, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195977&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Calculations-Master.PDF - Record of Conv FAA (item 10, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40195978&FileExtension=.PDF&FileName=Record%20of%20Conv%20FAA-Master.PDF - Photo 1. Fuel sample from right wing. (item 11, .PDF, 323 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40201430&FileExtension=.PDF&FileName=Photo%201.%20%20Fuel%20sample%20from%20right%20wing.-Master.PDF - Photo 2. Fuel sample from left wing. (item 12, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40201431&FileExtension=.PDF&FileName=Photo%202.%20%20Fuel%20sample%20from%20left%20wing.-Master.PDF - Photo 3. Top spark plugs, cylinders #1, 3 & 5. (item 13, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40201432&FileExtension=.PDF&FileName=Photo%203.%20%20Top%20spark%20plugs,%20cylinders%20%231,%203%20%26%205.-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.