# NTSB SEA05FA136: Beech E-55, N686T, Lopez, WA, July 2, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 1, 2005, 18:55 local (Jul 2, 2005, 01:55 UTC) - Place: Lopez, WA - Coordinates: 48.48389, -122.937774 - Nearby events: https://openairdocs.org/map.md?lat=48.4839&lon=-122.9378&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 2 serious, 1 minor - Status: Completed, report August 29, 2006 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Raytheon Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 61879 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA05FA136 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61879/pdf - Page: https://openairdocs.org/ntsb/SEA05FA136 ## Probable cause The pilot's failure to refuel the airplane which resulted in a dual loss of engine power during normal descent due to fuel exhaustion. A contributing factor was the incorrect installation of the left and right wing fuel sight gage/float assemblies by unknown persons, resulting in a false indication on the wing fuel sight gages. ## Analysis According to the pilot, during his preflight inspection, he determined the fuel aboard the airplane by looking at the wing fuel sight gauges. The left and right fuel sight gauges indicated 45 gallons and 55 gallons, respectively, which was "sufficient" fuel for the planned 1 hour 50 minute cross country flight. During the flight, both engines lost power, and the pilot ditched the airplane in ocean waters about 8 nautical miles short of the destination airport. Review of maintenance records indicated that about 4 months before the accident, fuel leaks in the airplane's left and right wings were repaired by replacing the right hand outboard and left hand inboard leading edge fuel cells. This repair involved replacement of both wing fuel sight gauges. According to one of the two mechanics who performed the work, when the sight gauges were removed to replace the tanks, he and the other mechanic marked the sight gauges "R" and "L" and made hash marks on the mounting plates. When they reinstalled the sight gauges, they used the hash marks to put them back in their original positions. Interviews of the airplane's owner and another mechanic provided conflicting information about whether the fuel sight gauges had been repositioned by this mechanic following completion of the fuel cell repair work. Review of the Pilot's Operating Handbook revealed that the fuel sight gauges are to be used for partial filling or off-loading of fuel and only when the gauge reads within the calibrated area between 40 and 60 gallons. When the airplane was examined, the fuel tanks were empty. The right wing fuel sight gauge indicated 55 gallons. The left wing fuel sight gauge initially indicated in the cross hatched area; but after it was jiggled, it indicated 43 gallons. When the fuel sight gauge access plates were removed, it was noted that black felt tip pen marks (hash marks) on the fuel sight gauge mount plates and on the fuel sight gauges did not align. Further examination revealed that the gauges were installed improperly, such that the floats were restricted in their range of travel by the wing structure. When the gauges were rotated to a position where the hash marks aligned, the gauge floats had a full range of travel, and both gauges indicated in the cross hatched (unusable) area. Information provided by the airplane's owner and a trip book found in the airplane indicated that at the time the pilot conducted his preflight and at the time of the accident, the airplane had been flown 3.9 hours and 5.5 hours, respectively, since its last refueling. Using the fuel burn rate provided by the owner of 30 gallons per hour, the airplane would burn 165 gallons of fuel in 5.5 hours. Further, in the 3.9 hours flown by the owner, the airplane would burn 117 gallons. Subtracting 117 gallons from the airplane's usable fuel capacity of 166 gallons indicated that when the pilot preflighted the airplane, it contained about 49 usable gallons of fuel with each wing holding about 24.5 usable gallons of fuel. If the sight gauges had been properly installed, they would have read in the cross hatched (unusable) area. The airplane was equipped with left and right fuel quantity indicators mounted in the instrument panel. According to the owner, these indicators did not work properly and several maintenance facilities had worked on them without resolving the problem. He and other family members who flew the airplane (including the accident pilot) used the sight gauges to determine the amount of fuel aboard the airplane for partial fuel loads. ## Factual narrative HISTORY OF FLIGHT On July 1, 2005, about 1855 Pacific daylight time, a Beech E-55 twin-engine airplane, N686T, experienced a loss of power from both engines and ditched in ocean waters near Lopez Island, Washington, about 8 miles southeast of the flight's planned destination of Friday Harbor, Washington. The airplane, which was registered to a private individual and operated by the commercial pilot, was destroyed by impact damage and immersion in salt water. Of the five people aboard, two passengers sustained fatal injuries, the pilot and one passenger sustained serious injuries, and one passenger sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the personal cross country flight conducted under 14 CFR Part 91. The flight departed from Redmond, Oregon, about 1713. In a written statement submitted to the NTSB investigator-in-charge (IIC), the pilot reported that on the afternoon of July 1, 2005, he and one of his passengers (who was a private pilot) pulled the airplane out of its hangar at Roberts Field in Redmond and conducted a pre-flight inspection. He explained that "the way to visually inspect the fuel level on this plane is to check the float gauges on the wing, which for the past eleven years of ownership, [have] been pin-point accurate. The left engine had 45 gallons (3 hours) and the right engine had 55 gallons (3:45 hours), and both engines had 11 qts. of oil. This was a sufficient amount of fuel for an hour and fifty minute flight." The pilot reported that the flight from Redmond to Friday Harbor proceeded uneventfully until they were "a few miles north of Seattle airspace." As he was waiting for Whidbey Island Naval Air Station Approach Control to respond to his request for an instrument flight rules (IFR) clearance to descend through an overcast cloud layer, the right engine started "surging." He asked Whidbey Approach to expedite his request, and they cleared him to descend through the cloud layer and gave him a vector to Friday Harbor. The pilot turned the auxiliary fuel pumps on low, and "the engine began to act somewhat normally." After descending through the clouds and with the airport in sight, he cancelled his IFR flight plan and changed to the common traffic advisory frequency (CTAF) for Friday Harbor. "Soon after," the right engine began surging again. "After several minutes," the left engine started surging. His attempts to remedy the situation were unsuccessful. The pilot stated that "the engines never shut down, but there wasn't sufficient thrust to keep us in the air, and the plane started to lose altitude." He realized they were descending below the elevation of the cliff top on Lopez Island and turned away from the cliff. "Within seconds of turning away from the cliff," the airplane impacted the water and "almost immediately began sinking." According to information provided by air traffic control personnel, after departing from Redmond, the pilot contacted the Seattle Air Route Traffic Control Center (ARTCC) and requested and received visual flight rules (VFR) flight following. As the flight proceeded towards Friday Harbor, Seattle ARTCC handed the flight off to Seattle Terminal Radar Approach Control (TRACON). The pilot reported no difficulties with the airplane during the time the flight was in contact with Seattle ARTCC and Seattle TRACON. At 1839, Seattle TRACON handed the flight off to Whidbey Island Naval Air Station Approach Control. The pilot made a request to Whidbey Approach for an IFR clearance to Friday Harbor. Whidbey Approach issued an IFR clearance and subsequently pointed out the position of the Friday Harbor Airport to the pilot. At 1849, the pilot acknowledged that he had the airport in sight and cancelled the IFR clearance. Whidbey Approach then cleared the pilot to switch to the CTAF for the airport. During the time the pilot was communicating with Whidbey Approach, he reported having an engine problem, but when queried by the controller prior to the frequency change to CTAF, he reported the flight did not require any assistance. Whidbey approach did not receive any distress calls from the airplane; however, the pilot of another airplane reported to the controller that he had witnessed the airplane impact the water near the south end of Lopez Island. According to information provided by the San Juan County Sheriff's Office, about 1855, emergency operators in Friday Harbor received multiple reports of the airplane "crash landing" in the waters just south of Lopez Island in an area known as Davis Bay. When emergency responders arrived on the scene, the airplane was completely submerged, and they found four people in the water, one of whom was unresponsive and was pronounced deceased by emergency medical personnel. One of the survivors told the responders that one passenger had not exited the airplane before it sank. About 2100, San Juan County Sheriff's Office divers entered the water and located the airplane approximately 150 feet from shore, at a depth of about 54 feet, latitude 48:26.690 north, and longitude 122:53.414 west. PERSONNEL INFORMATION The pilot, who was seated in the left front seat, held a commercial pilot certificate with airplane single engine land and instrument ratings. Additionally, he was rated as a private pilot in multi-engine land airplanes. He held a first class medical certificate dated September 11, 2003, with the limitation, must wear corrective lenses. The pilot reported that he had accumulated 290 hours total flight time with 4 hours flown in the past 90 days. Additionally, he reported that he had accumulated 150 hours in the Beech E-55 airplane. The pilot rated passenger, who was seated in the right front seat, held a private pilot certificate with single and multi-engine land airplane ratings and the limitation, night flying prohibited. He held a third class medical certificate dated September 15, 2003, with the limitation, must have available glasses for near vision. On the application for his most recent medical certificate, the passenger reported that he had accumulated 450 hours total flight time with 25 hours flown in the past six months. AIRCRAFT INFORMATION The airplane's total fuel capacity was 172 gallons of which 166 gallons were usable. Each wing contained three fuel cells, an outboard leading edge cell, an inboard leading edge cell, and a wing box section fuel cell. The cells were interconnected to provide 83 gallons usable fuel in each wing. One flush-type filler cap was located in the outboard end of each outboard wing leading edge fuel cell. The Pilot's Operating Handbook for the airplane stated that "fuel quantity is measured by float type transmitter units which transmit the common level indication to a single indicator [on the instrument panel] for each respective wing system." The Handbook also stated that "a visual fuel level sight gage in each wing leading edge, outboard of the engine nacelle, can be used for partial filling or off-loading of fuel. This gage is to be used only when it reads within the calibrated areas." (Examination of the airplane's fuel sight gauges revealed the calibrated area to be between 40 and 60 gallons.) Work orders documenting the most recent maintenance on the airplane were obtained from the facilities that performed the work. According to records obtained from one maintenance facility, the most recent annual inspection was completed on December 3, 2004, at an hour meter reading of 2,200.0 hours and a total airframe time of 3,753.5 hours. As of that date, the left engine, a Continental IO-520-C(7), S/N 816824-R, and the right engine, a Continental IO-520-C(7), S/N 816825-R, had both accumulated 431.8 hours since major overhaul. During examination of the wreckage, it was noted that the hour meter read 2,218.2 hours, indicating that when the accident occurred, the airplane had been flown 18.2 hours s ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, descent - normal - 2 engines - fuel system,fuel quantity float/sensor - movement restricted (contributing factor) - maintenance,installation - incorrect, unknown (contributing factor) - engine instruments,fuel quantity gage - false indication (contributing factor) - refueling - not performed, pilot in command (cause) - fluid,fuel - exhaustion (cause) - Forced landing, emergency descent/landing - Ditching, emergency descent/landing - terrain condition - water ## Aircraft - Registration: [N686T](https://openairdocs.org/deregistered/N686T-2008-07-14), registration cancelled 2008-07-14, S/N TE-986 (OpenAirDocs) - Reported make and model: Beech E-55 - Registry model: [Beech E-55](https://openairdocs.org/model/beech-e-55) (registry code 1152732) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TE-986 - Airframe hours: 3772 - Engines: Teledyne Continental IO-520-C 285 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 1, 2004, 18 hours before - Departed: RDM, Redmond, OR - Destination: FHR, Friday Harbor, WA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 21; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review September 1, 2003; seat: left; flight hours: 290 total, 150 in this make and model, 250 as pilot in command, 4 in the last 90 days, 2 in the last 30 days - Co-pilot; age 57; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; medical: class 3, with waivers/limitations; seat: right; toxicology performed; flight hours: 450 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 4,400 ft overcast - Temperature: 59 °F, dew point 52 °F - Altimeter: 30.04 inHg - Observed at: FHR, 8 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 20050702016529A](https://openairdocs.org/incident/20050702016529A), Jul 2, 2005: Beech E55, Lopez Island, WA, Destroyed, 2 fatal. (-23) On July 1, 2005, N686T ditched in the water off Lopez Island, Washington enroute to Friday harbor, Washington. 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.