# NTSB LAX08LA088: Beech F33A, N3133W, San Diego, CA, March 28, 2008 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 28, 2008, 16:15 local (23:15 UTC) - Place: San Diego, CA - Coordinates: 32.815555, -117.139442 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8156&lon=-117.1394&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report April 15, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 67776 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08LA088 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67776/pdf - Page: https://openairdocs.org/ntsb/LAX08LA088 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine controls: mixture control](https://openairdocs.org/ntsb-findings/01057602): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Beech F33A, 1 case](https://openairdocs.org/ntsb-findings/01057602/cases.md?model=1151425), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01057602/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech F33A, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151425), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech F33A, 1 case](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=1151425), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech F33A, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151425), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech F33A, 14 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151425), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech F33A, 8 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151425), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N3133W-2013-07-15), registration cancelled 2013-07-15, S/N CE-465, built 1973 (OpenAirDocs) - Reported make and model: BEECH F33A - Registry model: [Beech F33A](https://openairdocs.org/model/beech-f33a) (registry code 1151425) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CE 465 - Airframe hours: 7251 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: none; 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 (OpenAirDocs). - [Accident 20080328013129A](https://openairdocs.org/incident/20080328013129A), Mar 28, 2008: Beech F33A, San Diego, CA, Substantial damage. (-23) N3133W crashed in the dirt area approximately 250 feet from the end of runway 28 at Montgomery Field (myf) at 1615 on 03/28/2008. Aircraft came to rest… ## Other investigations on N3133W (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 CHI81FEX03](https://openairdocs.org/ntsb/CHI81FEX03), Oct 24, 1980: Beech F33A (N3133W), Indianapolis, IN, substantial damage 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.