# NTSB NYC95LA023: Beech 35-C33, N5869S, Coventry, RI, November 11, 1994 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 11, 1994, 14:30 local (19:30 UTC) - Place: Coventry, RI - Location: 41.7001° N, 71.6828° W: Placed by OpenAirDocs: center of Coventry, RI, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=41.7001&lon=-71.6828&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report May 16, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 38897 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC95LA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38897/pdf - Page: https://openairdocs.org/ntsb/NYC95LA023 ## Probable cause improper emergency procedures by the pilot and inadequate supervision by the flight instructor which resulted in their failure to restart the engine after it lost power due to a failed engine driven fuel pump. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, descent - normal - fuel system,pump - failure,total (cause) - emergency procedure - improper, dual student (cause) - supervision - inadequate, pilot in command(cfi) (cause) - Forced landing, emergency descent/landing - In flight collision with object, emergency descent/landing - object - tree(s) ## Analysis THE ENGINE LOST POWER WHEN THE INSTRUMENT STUDENT (PRIVATE) PILOT ATTEMPTED TO LEVEL THE AIRPLANE AT 3000 FEET MSL AFTER A DESCENT. THE FLT INSTRUCTOR TOOK CONTROL AND SET UP FOR A FORCED LANDING WHILE THE STUDENT PILOT ATTEMPTED TO RESTART THE ENGINE. THE AIRPLANE CAME TO REST IN TREES APPROX 1/4 OF A MILE FROM A PRIVATE ARPT. THE STUDENT HAD 250 HOURS OF TOTAL FLIGHT TIME, INCLUDING 77 HOURS IN TYPE. THE AIRPLANE WAS FOUND WITH THE ELECTRIC FUEL BOOST PUMP SWITCHED OFF AND THE STUDENT DID NOT MENTION IT WHEN INTERVIEWED ABOUT HIS EMERGENCY PROCEDURES. EXAMINATION OF THE AIRPLANE REVEALED THE ENGINE WOULD RUN WITH THE ELECTRIC FUEL BOOST PUMP ON, BUT WOULD NOT RUN USING THE ENGINE DRIVEN FUEL PUMP ONLY. THE ENGINE DRIVEN FUEL PUMP DRIVE SHAFT HAD FAILED AND THE BEARINGS WERE FROZEN. SMALL PARTICLES OF ALUMINUM WERE FOUND IN THE BEARINGS. THE PUMP HAD BEEN REMOVED FROM THE AIRPLANE, SHIPPED TO AN OVERHAUL FACILITY, AND RETURNED FOR INSTALLATION 52.3 HOURS PRIOR TO THE ACCIDENT. THE SOURCE OF THE PARTICLES WAS NOT DETERMINED. ## Factual narrative On November 12, 1994, at 1430 eastern standard time, a Beech 35-C33, N5869S, owned and operated by Paul Millman, of New York, New York, lost power, and made an off airport forced landing in Coventry, Rhode Island. The airplane was destroyed and the pilots were not injured. Visual meteorological conditions prevailed and the flight was operated on an instrument flight rules (IFR) flight plan under 14 CFR Part 91. The instructional flight originated at Danbury, Connecticut, with the owner/operator occupying the left seat and the flight instructor in the right seat. The flight had been in cruise flight at 7000 feet and was descended to 3000 feet. An unsigned statement, attached to the NTSB Operator report stated: ...leveling off at 3000 feet, the engine failed...the prop speed was 2450 rpm (almost full forward), manifold pressure between 15 in. and 20 in. (we used 15 in. for descent and 20 in. for cruise), and fuel flow prior to failure was about 12 GPH... KF (flight instructor) flew the plane, trimmed for best glide, while PM (pilot under instruction) handled communication and attempted to restart the engine. The airplane came to rest in trees 1/4 mile short of runway 27. FAA Inspector Mr. Arthur Rica, an airworthiness inspector with the Boston Flight Standards Field Office, reported that when he examined the airplane after the accident, the electric boost pump switch was off and there was no emergency checklist available in the cockpit. When interviewed by telephone on November 15, 1994, the pilot was asked about the procedures used to restart the engine, the pilot said he richened the mixture, and switched tanks. He said he did not notice the fuel flow, nor did he mention that he turned on the boost pump. The unsigned, attached statement to the accident report also stated: Attempts to restart included switching fuel tanks, activating auxiliary fuel pump, mixture rich, throttle full forward, switched magnetos. According to the Pilot's operating handbook, the procedure for loss of engine power include checking the fuel flow and if it is low, place the mixture to rich and turn on the auxiliary fuel pump. If no change after a few moments, the auxiliary fuel pump is to be turned off. The engine was run while attached to the fuselage. Mr. Rica reported that the engine performed satisfactorily with the electric fuel boost pump, but would not run on the engine driven fuel pump. Examination of the engine driven fuel pump disclosed the drive shaft had failed at the shear neck. The bearings were seized and contained small pieces of aluminum, of undetermined origin. According to documents supplied by the FAA, the engine driven fuel pump was removed from N5869S and shipped to Approved Aircraft Accessories, Inc, Romulus, Michigan. It was received on April 26, 1994, with a note stating that no fittings were installed. It was overhauled and tested on April 27, 1994. According to the overhaul manual, fittings must be installed for testing of the pump. The pump was returned to the facility that shipped the pump, Bluebird Aviation Corp, Danbury, Connecticut, where it was reinstalled on N5869S on April 28, 1994. According to a signed statement from the mechanic who installed the pump, "...[The pump] was received bare without any fittings installed. The pump had accumulated 52.3 hours at the time of the accident. ## Aircraft - Registration: [N5869S](https://openairdocs.org/deregistered/N5869S-2017-04-07), registration cancelled 2017-04-07, S/N CD-831, built 1965 (OpenAirDocs) - Reported make and model: BEECH 35-C33 - Registry model: [Beech 35-C33](https://openairdocs.org/model/beech-35-c33) (registry code 1151408) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: CD-831 - Airframe hours: 2789 - Engines: CONTINENTAL IO-470 225 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: Paul L. Millman - Registered owner: Super Structures - Airworthiness certificate: Standard, Utility - Last inspection: Annual, January 25, 1994, 70 hours before - Departed: DXR, DANBURY, CT - Destination: PVD, PROVIDENCE, RI - Flight plan: IFR - Airport: NONE, Riconn ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 6,900 total, 300 in this make and model, 6,700 as pilot in command, 125 in the last 90 days, 50 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 48 °F, dew point 23 °F - Altimeter: 30.00 inHg - Observed at: PVD, 16 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 19941111038199A](https://openairdocs.org/incident/19941111038199A), Nov 11, 1994: Beech 35C33, Coventry, RI, Destroyed. Lost power leveling after descent. Landed in trees. Failed use boost pump to restart. Engine driven pump failed. ## Other investigations on N5869S (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 MIA80DLD20](https://openairdocs.org/ntsb/MIA80DLD20), Dec 9, 1979: Beech C33 (N5869S), Ocala, FL, 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.