# NTSB LAX91LA228: Beech C-45H, N9903Z, Lake Elsinore, CA, May 29, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: May 28, 1991, 19:55 local (May 29, 1991, 02:55 UTC)
- Place: Lake Elsinore, CA
- Location: 33.6681° N, 117.3273° W: Placed by OpenAirDocs: center of Lake Elsinore, CA, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=33.6681&lon=-117.3273&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report May 27, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27219
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91LA228
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27219/pdf
- Page: https://openairdocs.org/ntsb/LAX91LA228

## Probable cause

FUEL STARVATION DUE TO AN IMPROPER MODIFICATION OF THE FUEL SYSTEM AND THE PILOT'S FAILURE TO ENSURE THAT THE AIRCRAFT WAS AIRWORTHY PRIOR TO FLIGHT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power, approach - vfr pattern - base leg/base to final
  - 2 engines
  - fluid,fuel - starvation (cause)
  - fuel system - inoperative (cause)
  - maintenance,modification - improper, company maintenance personnel (cause)
  - fuel system,fuel quantity float/sensor - erratic (contributing factor)
  - preflight planning/preparation - improper, pilot in command (contributing factor)
  - operation with known deficiencies in equipment - attempted, pilot in command
- Forced landing, descent - emergency
- In flight collision with terrain/water, descent - emergency
  - terrain condition - high vegetation
- Complete gear collapsed, landing - roll

## Analysis

THE PILOT SAID THAT HE WAS ASKED BY ONE OF THE OWNERS TO FERRY THE AIRCRAFT. WHEN HE ARRIVED TO GET IT HE FOUND THAT THE RIGHT ENGINE HAD BEEN SHUT DOWN DURING THE PREVIOUS FLIGHT. HE SAID THAT HE FOUND THE RIGHT FUEL TANK EMPTY AND ABOUT 20 GALLONS OF FUEL IN THE LEFT TANK. THE PILOT SAID HE LOADED 50 GALLONS OF FUEL IN EACH TANK, AFTER DETERMINING THAT THE FLIGHT WOULD REQUIRE ONLY 50 GALLONS. WHILE DESCENDING INTO LAKE ELSINORE ONE ENGINE QUIT FOLLOWED QUICKLY BY THE SECOND ONE AND THE PILOT LANDED IN A FIELD. FAA INSPECTORS FOUND THE RIGHT FUEL TANK CONTAINED NO FUEL AND THE LEFT TANK CONTAINED ABOUT 50 GALLONS. NO OTHER MECHANICAL MALFUNCTIONS OR FAILURES WERE IDENTIFIED DURING THE INVESTIGATION. ONE OWNER OF THE AIRCRAFT WHO WAS REPOSSESSING IT FROM A PARTNER SAID THAT AFTER THE ACCIDENT HE WAS INFORMED THAT DUE TO A PUMP FAILURE THE OTHER OWNER HAD 'SOMEHOW RIGGED THE AIRCRAFT SO THAT BOTH ENGINES WOULD BE SUPPLIED BY THE RIGHT FUEL TANK.' THE OWNER SAID THAT BOTH HE AND THE PILOT WERE UNAWARE OF THIS MODIFICATION.

## Aircraft

- Registration: [N9903Z](https://openairdocs.org/deregistered/N9903Z-2013-05-30), registration cancelled 2013-05-30, S/N AF-853, built 1961 (OpenAirDocs)
- Reported make and model: BEECH C-45H
- Registry model: [Beech C-45H](https://openairdocs.org/model/beech-c-45h) (registry code 1151018) (OpenAirDocs)
- Registry engine: [Pratt & Whitney R-985 series](https://openairdocs.org/engine/pratt-whitney-r-985-series) (registry code 52008, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: AF-853
- Engines: P&W R-985 450 horsepower reciprocating
- Damage: Substantial damage
- Flight: Positioning, Part 91
- Operator: Steve Malmborg
- Registered owner: Steve Malmborg
- Last inspection: Unknown, January 2, 2000
- Departed: 6CA7, ARVIN, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 36; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; flight hours: 3,000 total, 1,000 in this make and model, 30 in the last 90 days, 10 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Visibility: 10 statute miles
- Lowest ceiling: none

## 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 19910528017639A](https://openairdocs.org/incident/19910528017639A), May 28, 1991: Beech STC45, Lake Elsimore, CA, Substantial damage. Fuel starvation on final. Crashed short. Pilot unaware fuel modified right tank use only.

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.

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