LAX08LA088

NTSB accident investigation · Beech F33A · San Diego, CA · March 28, 2008

Accident · Minor injuriesLimited investigationFinal report
Date
March 28, 2008, 16:15 local (23:15 UTC)
Place
San Diego, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N3133WBeech F33A
Defining event
Approach-VFR pattern final: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 2009
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20080328013129A
Case key
67776

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

A loss of engine power due to fuel starvation as a result of the pilot's improper use of the mixture control.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine controls: mixture controlAircraft › Aircraft power plant · Incorrect use/operationBeech F33A: 1 caseAll aircraft: 41 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech F33A: 6 casesAll aircraft: 1,391 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeBeech F33A: 1 caseAll aircraft: 442 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot stated that she had leaned the mixture during cruise flight; however, she did not adjust the mixture setting prior to initiating an approach to landing. While on final approach to the runway, the engine lost power. The pilot advanced the throttle with no change in engine performance. The airplane landed hard in an open area just short of the approach end of the runway and impacted a ditch during the landing roll. Examination of the airplane by a Federal Aviation Administration inspector revealed that the firewall sustained substantial damage. The engine remained attached to the airframe by all its mounts. The engine was started and ran normally through various power settings. No anomalies were noted with the engine or airframe. The Pilot's Operating Handbook normal procedures state to enrich the mixture as required for descent and before landing.

Factual narrative

On March 28, 2008, about 1615 Pacific daylight time, a Beech F33A single-engine airplane, N3133W, landed short of the runway following a loss of engine power during final approach to landing at the Montgomery Field Airport (MYF), San Diego, California. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot sustained minor injuries. The airplane was substantially damaged. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The personal flight originated from Ramona, California, about 1600.

The pilot reported that during an uneventful flight, she had leaned the fuel mixture. She stated that she was cleared to land on runway 28L and proceeded to slow the airplane to 120 knots and extend the landing gear. About 2 miles from the runway on final approach, she heard a "slight whirl noise" followed by the engine losing power. She applied full throttle with no change in engine performance. Subsequently, the airplane landed hard in an open area about 250 feet short of the approach end of the runway and struck a ditch during the landing roll. The pilot reported to investigators she did not change the mixture setting during her approach to MYF. She added that from the time the engine lost power to the time the airplane impacted the ground was about 30 seconds.

Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the firewall sustained substantial damage. The engine remained attached to the airframe by all its mounts. The engine was started and ran normally through various power settings. No anomalies were noted with the engine or airframe.

The Beechcraft Bonanza F33A Pilot's Operating Handbook normal procedures state to enrich the mixture as required for descent and before landing.

Aircraft

Registration
N3133W
Reported as
Beech F33A
Category
Airplane
Serial number
CE 465
Airframe hours
7,251
Engine
Continental IO-550-B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2008
Departed
RMN · Ramona, CA
Destination
MYF · San Diego, CA
Airport
MYF · Montgomery Field, runway 28L, 3,401 × 60 ft, dirt

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
69
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 1, 2008
Seat
Right
Flight hours
1,959 total · 1,850 in this make and model · 1,898 as pilot in command · 41 in the last 90 days · 9 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 7 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 118 °F
Altimeter
29.89 inHg
Observed at
MYF

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N3133W · 1

Matched to the same aircraft by N-number and date.