# NTSB LAX05LA012: Beech C24R, N18942, Cloverdale, CA, October 22, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 21, 2004, 17:30 local (Oct 22, 2004, 00:30 UTC) - Place: Cloverdale, CA - Coordinates: 38.776111, -122.992774 - Nearby events: https://openairdocs.org/map.md?lat=38.7761&lon=-122.9928&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 28, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 60420 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX05LA012 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60420/pdf - Page: https://openairdocs.org/ntsb/LAX05LA012 ## Probable cause the loss of engine power due to fuel starvation from the pilot's inadequate fuel system management and his delay in selecting the fullest fuel tank. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, cruise - normal - fluid,fuel - starvation (cause) - fuel management - inadequate, pilot in command (cause) - fuel tank selector position - delayed, pilot in command (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency descent/landing - terrain condition - crop ## Analysis The airplane impacted vineyard crops during a forced landing following a loss of engine power while in cruise flight. The flight was intended to be a 30-minute trip between local airports. The pilot had the left fuel tank selected at the time of the power loss, and turned on the boost pump and selected the right fuel tank. The pilot was able to obtain a surge of power momentarily, but nothing more. He then setup for landing at the nearest airport. Upon noting his glide ratio would not allow them to reach the airport, he concentrated on landing in the vineyard. The airplane impacted the crops and was arrested by the crop trellis wires. Post-accident examination of the engine revealed no anomalies that would have prevented its normal operation. The left fuel tank contained 1 gallon of fuel and 11 gallons were in the right fuel tank. When electrical power was applied to the system, the fuel gages read values consistent with the fuel quantities found in the tanks. The unusable fuel quantity for each tank is 1.3 gallons. ## Factual narrative On October 21, 2004, at 1730 Pacific daylight time, a Beech C24R, N18942, impacted vineyard crops during a forced landing following a loss of engine power while in cruise flight near Cloverdale, California. The airplane was registered to, and operated by, the pilot under the provisions of 14 CFR Part 91 as a personal flight. The airplane sustained substantial damage. The private pilot and his pilot-rated passenger were not injured. Visual meteorological conditions prevailed, and a flight plan had not been filed. The cross-country flight departed Healdsburg, California (O31), at 1720, and was destined for Little River, California (O48). According to the pilot's written statement, the flight was expected to last 30 minutes. Five minutes after departing Healdsburg, at 2,600 feet, the engine lost power. The pilot established the best glide speed and headed toward Cloverdale. With the assistance of his pilot-rated passenger, he attempted to determine the cause of the power loss. The pilot attempted to restart the engine and was able to obtain a momentary surge of engine power, but nothing else. The pilot then concentrated on the ensuing forced landing. The pilot attempted to land at the Cloverdale airport, but the glide ratio fell short. The airplane neared a vineyard, and the pilot maintained a wings level attitude avoiding power lines where necessary and maintaining an airspeed above stall. The airplane set down in the vineyard and was halted by trellis wires. The airplane sustained substantial damage to the wings and horizontal stabilizer. The propeller blades were bent aft. The Sonoma County Sheriff Department personnel, who responded to the accident site, indicated that there was no fuel leak at the accident site. The sheriff department officer visually inspected the fuel tanks upon request from the National Transportation Safety Board investigator-in-charge (IIC), and reported observing no fuel in the left fuel tank and a nearly full right fuel tank. He also indicated that the airplane was resting nose low and he could not see if there was additional fuel toward the leading edge of the left fuel tank. While at the accident site, the pilot informed the officer that the engine began to run rough and abruptly stopped. The pilot attempted to restart the engine, and switched the fuel selector from the left to the right fuel tank, but the engine would not restart. The airplane was transported to Lakefront, California. A Federal Aviation Administration (FAA) inspector and mechanic examined the airplane, and noted that 1 gallon of fuel remained in the left fuel tank and 11 gallons remained in the right. The FAA inspector reported that the left fuel quantity gage depicted the fuel quantity in the red range past its "E" (empty) point. The right fuel quantity gage depicted the fuel quantity in the yellow range, which was below ½ a tank. The Safety Board IIC asked the mechanic to conduct an inspection of the engine to determine whether there were any problems with the engine's internal mechanisms. The crankshaft was rotated by manually rotating the propeller. The mechanic was able to obtain thumb compression on each cylinder confirming the integrity of the crankshaft, camshaft, connecting rods, pushrods, rocker arms, valves, and accessory section. The mechanic removed the J.P. Instruments (JPI) engine monitoring unit at the request of the Safety Board IIC and shipped it to the manufacturer to download the non-volatile information. According to the data provided by JPI, the engine's exhaust gas temperature (EGT) and cylinder head temperatures (CHT) remained relatively constant until the EGT decreased drastically near the end of the flight. The EGT spiked up to near the cruise setting twice prior to dropping off entirely. According to JPI, the EGT spikes could be associated with the engine surges noted by the pilot after the loss of engine power. The fuel system utilizes two 29.9-gallon tanks for a total fuel quantity of 59.8 gallons. The unusable fuel quantity is 1.3 gallons in each tank. ## Aircraft - Registration: [N18942](https://openairdocs.org/deregistered/N18942-2008-03-10), registration cancelled 2008-03-10, S/N MC-549, built 1977 (OpenAirDocs) - Reported make and model: Beech C24R - Registry model: [Beech C24R](https://openairdocs.org/model/beech-c24r) (registry code 1151254) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MC-549 - Airframe hours: 4338.8 - Engines: Lycoming IO-360-A1B6 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Jeffrey M. Osier-Mixon - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 2, 2004, 106.7 hours before - Departed: O31, Healdsburg, CA - Destination: O48, Little River, CA - Airport: O60, Cloverdale, runway 32, 3,155 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: none; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; last flight review June 1, 2004; seat: left; flight hours: 320 total, 175 in this make and model, 280 as pilot in command, 62 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 45 °F - Altimeter: 29.78 inHg - Observed at: STS, 17 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 20041021027659A](https://openairdocs.org/incident/20041021027659A), Oct 21, 2004: Beech C24R, Asti, CA, Substantial damage. (-23) Pilot departed healdsburg CA airport direct to little river CA airport (O48). Pilot and passenger witnessed that left hand fuel tank was selected. Engine… ## Other investigations on N18942 (1) 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. - [NTSB LAX93LA070](https://openairdocs.org/ntsb/LAX93LA070), Dec 19, 1992: Beech C24R (N18942), Oakland, CA, substantial damage. Probable cause: FUEL STARVATION DUE TO IMPROPER FUEL SYSTEM MANAGEMENT BY BOTH PILOTS AND THE FAILURE OF THE FLIGHT INSTRUCTOR TO ADEQUATELY SUPERVISE THE CONDUCT OF THE FLIGHT. 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.