# NTSB WPR11LA283: Beech A36, N2206L, El Monte, CA, June 24, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 23, 2011, 18:45 local (Jun 24, 2011, 01:45 UTC) - Place: El Monte, CA - Coordinates: 34.086112, -118.034721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.0861&lon=-118.0347&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report October 17, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO - NTSB case key (mKey): 80879 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11LA283 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/80879/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=80879 - Page: https://openairdocs.org/ntsb/WPR11LA283 ## Probable cause The pilot's failure to maintain adequate airspeed during the forced landing, which resulted in an aerodynamic stall and hard landing. Contributing to the accident was the loss of engine power due to fuel starvation as a result of the pilot's improper fuel management. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151604), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 8 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1151604), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech A36, 12 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=1151604), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech A36, 22 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151604), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1151604), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Beech A36, 4 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=1151604), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech A36, 15 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151604), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Beech A36, 31 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151604), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Beech A36, 7 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=1151604), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The airplane had just undergone an avionics and flight instrument upgrade, completed on the morning of the accident. The pilot had intended to fly the airplane on a cross-country flight later in the day; however, subsequent flights revealed a discrepancy in the fuel pressure indication system and the airplane was returned to the maintenance facility, where the problems were resolved later that afternoon. This was to be the first time the pilot had flown the airplane solo since the system upgrade and, although he was instrument rated, he did not want to perform an instrument flight rules approach with the new avionics. He was now in a hurry to depart and performed a cursory preflight inspection. He could not recall if he checked the fuel tank quantity or used a checklist. Ten minutes into the flight the engine experienced a total loss of power. The pilot was convinced that the loss of power was caused by a maintenance oversight and did not switch fuel tanks, perform any troubleshooting steps, or review the emergency checklist. He performed a forced landing and inadvertently allowed the airplane to stall as it turned from the base leg to the final leg of the traffic pattern. The airplane landed hard, bending both wing spars, collapsing the right main landing gear, and separating the nose gear. A postaccident examination revealed that the left fuel tank was empty and that the fuel selector valve was set to the left tank. The fuel lines from the selector valve to the engine were devoid of fuel. Additionally, data extracted from the engine monitoring system revealed that the pilot departed with an almost full right tank but limited quantities of fuel in the left tank. The data indicated that he subsequently continued the flight until the fuel in the left tank became exhausted. ## Factual narrative On June 23, 2011, about 1845 Pacific daylight time, a Beech A36, N2206L, landed hard after experiencing a loss of engine power at El Monte Airport, El Monte, California. The pilot operated the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot was not injured. The airplane sustained substantial damage. The personal flight departed Chino Airport, Chino, California, about 1835, with a planned destination of Camarillo Airport, Camarillo, California. Visual meteorological conditions prevailed, and no flight plan had been filed. The airplane had just undergone an avionics and flight instrument upgrade at a maintenance facility at Chino Airport. At 1300, an employee from the facility flew the airplane to Van Nuys to pickup the pilot. During the outbound and return flights he observed a spurious fuel pressure indication on the engine monitoring system. The engine appeared to operate normally, and it was assumed that the problem was associated with the indication system. The airplane landed at Chino uneventfully, and for the next 3 hours technicians diagnosed and rectified the malfunction by disconnecting and cleaning out the fuel pressure monitoring lines. The pilot had initially planned to fly the airplane to Concord, California, that afternoon; however, due to the delay he decided to fly the airplane back to his residence in Camarillo, and complete the rest of the journey via commercial airline. He reported that the maintenance delay had left him tired and frustrated, and that he declined an offer by the maintenance facility manager to drive him to the airport for the commercial flight. This was to be the first time he had flown the airplane solo since the installation of the new system, and although he was instrument rated, he did not want to perform an instrument flight rules (IFR) approach with the new panel. He called flight service for a weather briefing, and although the weather was clear, the briefer recommended that the pilot call back after 1800 for an update. About 1800, the pilot performed what he described as a cursory walk-around, and then checked back for a weather update. He could not recall if he checked the fuel tank quantity or used his checklist at that time. He reported an uneventful takeoff and initial cruise to 4,500 feet agl. He stated that he normally flies higher, but on this occasion, he was in a hurry. During the initial cruise, he became concerned, and was distracted when sun glare began to interfere with his traffic scan and outside visual reference. Shortly thereafter he heard a popping sound emanate from the engine, followed by a total loss of power. The propeller continued to turn, but the airplane immediately began to descend. He contacted Air Traffic Control, notifying them of the emergency, and received vectors to El Monte. He stated that he became convinced that the loss of power was due to a maintenance oversight performed earlier in the day, and as such, hedid not think to switch the fuel tank selector, turn on the fuel boost pump, or perform any other troubleshooting steps. He maintained an airspeed of 90 knots during the descent, and stated that during the turn to final he inadvertently allowed the airplane to stall. The airplane landed hard, bending both wing spars, collapsing the right main landing gear, and separating the nose gear. Post accident examination by the NTSB investigator-in-charge revealed that the right wing main fuel tank contained fuel to the brim of the filler cap. The left main tank appeared empty when viewed through the filler cap, and about 12 ounces of fuel was subsequently drained from the wing sump. Neither main fuel tank appeared to have been breached during the accident sequence. Further examination of the fuel system revealed about 2 teaspoons of fuel in the belly-strainer, and 6 drops of total fuel in the lines from the strainer through to the fuel injector servo. No fuel staining or indications of a fuel leak were noted. A member of the fire crew, who responded to the accident site, reported that the fuel selector valve was in the left tank position immediately following the accident. The airplane was equipped with an Electronics International, Inc., MVP-50 engine analyzer and systems monitor. The MVP-50 is capable of recording engine and airplane system parameters at 1 second intervals. The data from the day's three flights were downloaded and examined. The data revealed that for the final flight the engine started at 1807, with the left fuel tank quantity gauge indicating 9 gallons of total fuel, and the right tank indicating 34.5 gallons. For the next 20 minutes, the engine speed remained at approximately 1100 rpm, with intermittent increases to about 2,000 rpm. At the end of that period the right tank fuel quantity remained constant, with the left tank indicating 6.5 gallons. At 1627, the engine speed increased to 2,570 rpm, with a corresponding fuel pressure increase to 100 pounds per square inch (psi). For the next 2 minutes, the right fuel tank level, engine speed, and fuel pressure remained constant, with the left fuel tank level now indicating 2.5 gallons. After a few seconds, the left tank level dropped to 0 gallons, followed 8 minutes later by an engine speed and fuel pressure decrease to 1,400 rpm, and 1.5 psi, respectively. The data recording ended 4 minutes later. ## Aircraft - Registration: [N2206L](https://openairdocs.org/deregistered/N2206L-2013-09-12), registration cancelled 2013-09-12, S/N E-917, built 1976 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-917 - Airframe hours: 2821 - Engines: Lycoming TIO 540 350 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2011, 12 hours before - Departed: CNO, Chino, CA - Destination: CMA, Camarillo, CA - Airport: EMT, El Monte, runway 01, 3,995 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review March 8, 2011; seat: left; flight hours: 3,184 total, 2,434 in this make and model, 2,820 as pilot in command, 7 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 59 °F - Altimeter: 29.87 inHg - Observed at: CQT, 12 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 20110623012969A](https://openairdocs.org/incident/20110623012969A), Jun 23, 2011: Hawker/Beech A-36, El Monte, CA, Substantial damage. A-36 was VFR and enroute from chino, CA to camarillo, CA when pilot reported loss of engine power and diverted to El Monte, CA airport (EMT). Aircraft made a… ## Docket (8 files) The files NTSB released with the investigation on September 8, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=80879. 2.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350658&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350659&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Fire Crew Statement (item 3, .PDF, 2 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352744&FileExtension=.PDF&FileName=Fire%20Crew%20Statement-Redacted.PDF - MVP-50 Engine and Systems Monitor Data (item 4, .CSV, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350661&FileExtension=.csv&FileName=MVP-50%20Engine%20and%20Systems%20Monitor%20Data-Master.csv - Photo 1 - Accident Site. Photo Taken By Airport Manager (item 5, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350662&FileExtension=.PDF&FileName=Photo%201%20-%20Accident%20Site.%20Photo%20Taken%20By%20Airport%20Manager-Master.PDF - Photo 2 - Left Fuel Tank Filler Neck (item 6, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350663&FileExtension=.PDF&FileName=Photo%202%20-%20Left%20Fuel%20Tank%20Filler%20Neck-Master.PDF - Photo 3 - Right Fuel Tank Fuel Cap (item 7, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350664&FileExtension=.PDF&FileName=Photo%203%20-%20Right%20Fuel%20Tank%20Fuel%20Cap-Master.PDF - Photo 4 - Belly Strainer Fuel (item 8, .PDF, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350665&FileExtension=.PDF&FileName=Photo%204%20-%20Belly%20Strainer%20Fuel-Master.PDF 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.