# NTSB NYC94FA064: Swearingen SA-26AT, N20PT, Winchester, VA, March 18, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 18, 1994, 00:50 local (05:50 UTC) - Place: Winchester, VA - Coordinates: 39.139286, -78.280799 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.1393&lon=-78.2808&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report November 18, 1994 - Report: Approved by Office Director - Safety recommendations: Yes - NTSB case key (mKey): 38668 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC94FA064 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38668/pdf - Page: https://openairdocs.org/ntsb/NYC94FA064 ## Probable cause THE PILOT'S DECISION TO OPERATE THE AIRPLANE WITH KNOWN DEFICIENCIES IN THE FUEL QUANTITY MEASURING SYSTEM WHICH RESULTED IN A POWER LOSS DUE TO FUEL STARVATION, FOLLOWED BY IMPROPER EMERGENCY PROCEDURES WHICH RESULTED IN A LOSS OF CONTROL INFLIGHT AND UNCONTROLLED CONTACT WITH THE GROUND. FACTORS WERE THE LACK OF A REQUIREMENT FOR PERIODIC CALIBRATION OF THE FUEL QUANTITY MEASURING SYSTEM FROM THE MANUFACTURER, AND THE ERRATIC AND INACCURATE FUEL QUANTITY MEASURING SYSTEM. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, approach - vfr pattern - final approach - fuel system,fuel quantity float/sensor - erratic (contributing factor) - fuel system,fuel quantity float/sensor - false indication (contributing factor) - operation with known deficiencies in equipment - performed, pilot in command (cause) - fluid,fuel - starvation (contributing factor) - in-flight planning/decision - inadequate, pilot in command (cause) - Loss of control - in flight, approach - vfr pattern - final approach - emergency procedure - improper, pilot in command (cause) - directional control - not maintained, pilot in command (cause) - airspeed - not maintained, pilot in command (cause) - stall/mush - inadvertent, pilot in command (cause) - In flight collision with object, descent - uncontrolled - object - tree(s) - On ground/water encounter with terrain/water, descent - uncontrolled ## Analysis WHILE ON APP AT NIGHT, IN VMC, THE LEFT ENG LOST PWR DUE TO FUEL STARVATION. THE PROP WAS NOT FEATHERED, THE L/G WAS LEFT DOWN, AND THE A/C DRIFTED LEFT OF CRS, STRUCK TREES, AND THEN THE GND. ONE GAL OF FUEL WAS DRAINED FROM THE RT WING, ENG, & FUEL LINE. NO FUEL WAS FOUND IN THE LT WING, ENG & FUEL LINE. THE CO-PILOT SAID THE FUEL QTY SYS WAS ERRATIC WITH THE LT SIDE MORE ERRATIC, AND THE RT SIDE READING ABOUT 10 GAL MORE THAN THE LT SIDE. TESTING FOUND THE RT SIDE INDICATED ABOUT 45 GAL MORE THAN WAS PRESENT WHILE THE LT SIDE WAS INOP. THERE WAS NO REQUIREMENT FOR PERIODIC RECALIBRAION OF THE FUEL QTY SYSTEM. THE OWNER/PILOT HAD OPERATED THE A/C ON 32 FLTS, OVER 23 HRS, AND REFUELED 23 TIMES USING PARTIAL FILLS, SINCE HE HAD FULL TANKS. THE PILOT WAS CHECKED OUT 17 MONTHS PRIOR AND THE INSTR SAID THE PILOT WAS FINE, HOWEVER, HE WAS CAUTIONED HIM TO ENROLL IN RECURRENT TRAINING. THERE WAS NO RECORD HE DID. THE PILOT HAD RECEIVED AN FAA CHECKRIDE 19 MONTHS PRIOR TO THE ACCIDENT, WHICH HE PASSED. ## Factual narrative HISTORY OF FLIGHT On March 18, 1994, at 0050 eastern standard time, a Swearingen SA-26AT, Merlin IIB, N20PT, experienced a partial power loss and collided with the ground while attempting to land at the Winchester Regional Airport (W16), Winchester, Virginia. The pilot, the sole occupant, received fatal injuries, and the airplane was destroyed. Visual meteorological conditions prevailed and no flight plan was filed for the positioning flight which was being conducted under 14 CFR Part 91. There was no record of the airplane receiving any services prior to departure. The flight departed from Dulles International Airport (IAD), at 0029. The pilot requested and received visual flight rules advisories from Dulles Approach Control until he reported Winchester Regional Airport in sight at 0036, and was cleared to leave the frequency. A pilot waiting in the pilot lounge of the Winchester Airport, reported he heard the pilot of N20PT, call on UNICOM frequency, that he was turning final for runway 32. He said he heard no other transmissions from the pilot. A witness, reported she heard a "whoosh" followed by a "thump" and looked out her window and saw the airplane in the yard. She said she did not remember smelling fuel when at the accident site. A person at the accident site said he, "did not detect a strong odor of fuel." The accident occurred during the hours of darkness at location 39 degrees, 08 minutes North and 78 degrees, 08 minutes West. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with limitations for airplanes single and multi-engine land, and instrument airplane. In addition, he held a 2nd class FAA airman medical certificate, issued on March 7, 1994. The last entry in the pilot's log book was dated February 23, 1993. The log book showed a total flight time of 2672 hours, with 178 hours in the Swearingen SA-26AT. Based upon hours flown that were recorded in the maintenance records, the pilot was estimated to have flown the airplane an additional 390 hours. AIRCRAFT INFORMATION The airplane was a 1969 year model Swearingen SA-26AT, Merlin IIB. It was powered by two Garrett TPE-331-1-151G engines which developed 665 horse power. It was maintained under a manufacturers inspection program. The total time on the airframe was 5869 hours and the airplane had flown 67 hours since the last inspection. METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed. The airport was served by an Automatic Weather Observation Service (AWOS) which recorded the following weather at 0045: clear below 12,000 feet, visibility 10 miles, temperature 36 degrees F, dewpoint 12 degrees F, wind from 270 degrees at 5 knots, altimeter 29.81 in/hg. WRECKAGE AND IMPACT INFORMATION The airplane was examined at the accident site on March 18 - 20, 1994. The airplane had struck trees prior to ground contact and then impacted on the lawn of an unoccupied residence, 250 feet short of the approach end of runway 32 and 1100 feet to the left of runway centerline, on a heading of 270 degrees. The fuselage was rolled 15 degrees left. The fuselage was intact and crushing was visible on the lower portion. Both horizontal stabilizers and elevators were bent downward and touched the ground. The vertical stabilizer and rudder were separated from the airframe and laying behind the left elevator. All flight control cables were intact. The landing gear was extended. The nose landing gear was driven forward and the two main landing gear were driven aft. The wing flaps were extended to 30 degrees. The fuel shutoffs were open and the crossflow valve was closed. Both RPM levers were in the high position. The left power lever was in the low position and the right power lever was midrange. Both stop and feather buttons were in the closed position (non-feather). On the left engine, the propeller was not feathered. Two propeller blades were bent rearward and one blade showed no evidence of ground contact. The left engine fuel filter and line leading to it were empty. Small particles of mud were found impregnated on the igniter plug cooling holes, and mud was found in the engine inlet. The leading edge of the impeller blades in view were straight with no visible nicks, or foreign object damage. On the right engine, the propeller was not feathered. All three blades were bent rearward and twisted opposite the direction of rotation. The right engine fuel filter and line leading to it were full of fuel. Brown organic matter was found adhered to the igniter plug and impregnated in the cooling holes. Mud was found in the engine inlet. The leading edge on two impeller blades had curled corners opposite the direction of rotation with leading edge nicks. Approximately one gallon of fuel was drained from the right wing of the airplane. No fuel was found in the left wing which was damp. Both wings tanks had ruptures. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted on March 18, 1994, by Francis P. Field, M.D., Office of the Chief Medical Examiner, Northern Virginia District, Fairfax, Virginia. Toxicological testing was conducted by the Commonwealth of Virginia, and the FAA Civil Aeromedical Institute, in Oklahoma City, Oklahoma, and was negative for drugs and alcohol. TESTS AND RESEARCH The outboard left fuel float (L-4) was examined by the Safety Board Metallurgical Laboratory. The wiper which contacts the surface of the rheostat, had separated from the wiper arm. According to Metallurgist's Factual Report 94-111, ...The microscopic fracture features on the fracture face...were almost completely obliterated by post- separation rubbing...Small relatively undamaged regions of the fracture...contained dimpled fracture characteristics, consistent with overstress separations...." Both engines were shipped to Allied Signal in Phoenix, Arizona, for teardown which was witnesses by the FAA. According to the summary of findings on the right engine from Allied Signal, "...Engine operation at the time of ground impact was evidenced by the heat discolored dirt and debris on the inside surfaces of the combustion chamber and the turbine rotor blades and stator vanes. Additional evident of engine operation was the fractured planetary gear carrier mounting lugs." According to the summary of findings on the left engine from Allied Signal, there was engine rotation at ground impact. Six soil samples were taken from under the wings and one was taken from a control site away from the main wreckage where one gallon of jet fuel had been poured on the ground. Samples 1, 2 and 3, were taken under the left wing and produced readings of 1,037 mg/kg, 759 mg/kg, and 522 mg/kg. Samples 4, 5, and 6 were taken under the right wing and produced readings of 17,600 mg/kg, 38,300 mg/kg, and 255 mg/kg. The test sample reading was 10,409, mg/kg. These readings measured the hydrocarbon level in milligrams per kilogram of earth. All samples were all taken at similar depths of 6 inch depth below the ground. ADDITIONAL INFORMATION FUEL SYSTEM Fuel was contained in two wing tanks, connected by a cross- flow valve which when opened, allowed fuel to flow between the two tanks, seeking an equal level. The total fuel capacity of the tanks was 388 gallons with a useable amount of 386 gallons (2624.8 lbs @ 6.8 lbs/gal). According to airplane log book records, the empty weight of airplane was 6604 lbs, and the maximum gross takeoff weight was 10,000 lbs. Fuel quantity was determined by four float-type transmitters, and one adjustable potentiometer, per wing. Each transmitter was a variable rheostat in which the resistance increased with fuel quantity. The cumulative resistance of each wing was displayed in the cockpit as fuel quantity ## Aircraft - Registration: [N20PT](https://openairdocs.org/deregistered/N20PT-2013-09-24), registration cancelled 2013-09-24, S/N T26128, built 1969 (OpenAirDocs) - Reported make and model: SWEARINGEN SA-26AT - Registry model: [Swearingen SA-26AT](https://openairdocs.org/model/swearingen-sa-26at) (registry code 8780112) (OpenAirDocs) - Registry engine: [AiResearch 331SER 705HP](https://openairdocs.org/engine/airesearch-331ser-705hp) (registry code 01506, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: T26-128 - Airframe hours: 5869 - Engines: GARRETT TPE-331-1-151 665 horsepower turbo prop - Damage: Destroyed - Flight: Positioning, Part 91 - Registered owner: Bobby R. Venable - Airworthiness certificate: Standard, Normal; Special, Provisional (Special) - Last inspection: Continuous airworthiness, January 16, 1994, 67 hours before - Departed: IAD, WASHINGTON, DC - Airport: W16, Winchester Regional, runway 32, 5,500 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 3,382 total, 568 in this make and model, 3,330 as pilot in command, 67 in the last 90 days, 30 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 270° at 5 knots - Visibility: 10 statute miles - Temperature: 36 °F, dew point 12 °F - Altimeter: 29.00 inHg - Observed at: W16 ## 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 19940318005589A](https://openairdocs.org/incident/19940318005589A), Mar 18, 1994: Swrngn SA226AT, Winchester, VA, Destroyed, 1 fatal. Night approach. Lost left engine due fuel starvation. Not feathered. Gear down. Below VMC. Hit trees. Bad gauges. 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.