WPR12LA309

NTSB accident investigation · Beech A36 · Rock Springs, WY · June 22, 2012

Accident · No injuriesLimited investigationFinal report
Date
June 22, 2012, 11:00 local (17:00 UTC)
Place
Rock Springs, WY
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4972MBeech A36
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20120622021339A
Case key
84361

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The total loss of engine power due to fuel starvation because of the incorrectly installed fuel cap. Contributing to the accident was the pilot’s decision to continue the flight using fuel from the left fuel tank after she observed fuel streaming from the left fuel tank cap.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fuel system: fuel storageAircraft › Aircraft systems · Incorrect use/operationBeech A36: 1 caseAll aircraft: 60 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech A36: 22 casesAll aircraft: 1,695 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that during an uneventful flight, she continued past her original destination to another destination. Shortly thereafter, the pilot observed fuel streaming from the left fuel tank cap and noted that the left fuel tank gauge indicated that the tank was about 3/4 full. The pilot continued the flight toward her new destination while continuing to use fuel from the left fuel tank. As the airplane neared the new destination, the pilot observed that the left fuel tank was about 1/2 full; the engine then lost power. After the engine lost power, the pilot switched fuel tanks and advanced both the throttle and mixture control levers; however, the engine did not restart, so she performed an off-airport landing to an open field. During a postaccident interview, the pilot stated that the fuel cap was not secured properly after refueling. As a result, fuel was siphoned from that fuel tank during the flight. Further, because the pilot had chosen to continue operating on that fuel tank, the engine lost power due to fuel starvation. A pressure differential likely resulted in the inaccurate fuel gauge indication. Examination of the left fuel tank cap and seal revealed no evidence of any preexisting anomalies that would have precluded normal operation.

Factual narrative

On June 22, 2012, about 1100 mountain daylight time, a Beech A36, N4972M, was substantially damaged during a forced landing near Rock Springs, Wyoming. The airplane was registered to Waldo Air, Bend, Oregon, and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot, sole occupant of the airplane, was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The cross-country flight originated from the Bend Municipal Airport (BDN), Bend, Oregon, at 0717 Pacific daylight time with an intended destination of Rock Springs, Wyoming. In a written statement to the National Transportation Safety Board (NTSB) investigator-in-charge, the pilot reported that she originally intended on landing in Gooding, Idaho, however, decided to continue to Rock Springs, Wyoming, since the flight was going well. After passing Gooding, she noticed fuel streaming out of the left wing fuel tank cap and observed the left fuel gauge indicating three-quarters of a tank of fuel. The pilot stated that she continued to use fuel from the left fuel tank until about 25 miles west of Rock Springs, where she noted that the left wing fuel tank gauge showed a level of about half. Subsequently, the engine “quit abruptly” at an altitude of about 1,500 feet above ground level (agl). The pilot switched to the right fuel tank and advanced the throttle and mixture, however, the engine did not restart and she initiated a forced landing to an open field. During the landing roll, the nose gear collapsed. The pilot added that she should have turned the fuel boost pump on and attempted the restart procedure, however, did not have a lot of time to do so since the airplane was at an altitude of about 1,000 feet agl. According to a Federal Aviation Administration inspector, the pilot reported that the fuel cap was not secured properly after refueling. Damage to the airplane was determined to be substantial about one month after repairs to the airplane had begun. The repair facility reported that the nose gear was compressed aft into the engine firewall. The engine overhaul facility reported that no mechanical anomalies were noted with the engine during the overhaul process. Examination of the left and right fuel tank cap and seals by an NTSB investigator revealed no evidence of any preexisting anomalies.

Aircraft

Registration
N4972M
Reported as
Beech A36
Category
Airplane
Serial number
E-1275
Airframe hours
3,209
Engine
Cont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Jana VanAmburg
Registered owner
Waldo Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 1, 2012
Departed
Bend, OR
Destination
Rock Springs, WY

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 3
Last flight review
September 29, 2011
Seat
Left
Flight hours
942 total · 110 in this make and model · 742 as pilot in command · 16 in the last 90 days · 4 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 18 °F
Altimeter
29.96 inHg
Observed at
RKS, 25 nm away

Docket · 6

The files NTSB released with the investigation on August 27, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.