# NTSB WPR12LA309: Beech A36, N4972M, Rock Springs, WY, June 22, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 22, 2012, 11:00 local (17:00 UTC) - Place: Rock Springs, WY - Coordinates: 41.596942, -109.065002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.5969&lon=-109.0650&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 6, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 84361 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA309 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84361/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84361 - Page: https://openairdocs.org/ntsb/WPR12LA309 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel storage](https://openairdocs.org/ntsb-findings/01022810): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01022810/cases.md?model=1151604), [All aircraft, 60 cases](https://openairdocs.org/ntsb-findings/01022810/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) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); 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) - [Enroute-cruise: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N4972M), registered now, S/N E-1275, built 1978 (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-1275 - Airframe hours: 3209 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; 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 ## 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 20120622021339A](https://openairdocs.org/incident/20120622021339A), Jun 22, 2012: Beech A36, Rock Springs, WY, Substantial damage. On 06/22/2012, at approximately 1330 hrs. MDT, N4972M, a Beechcraft model A36 bonanza aircraft sustained substantial damage when it impacted terrain near Rock… ## Docket (6 files) The files NTSB released with the investigation on August 27, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84361. 7.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399050&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Correspondence (item 2, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399051&FileExtension=.PDF&FileName=FAA%20Correspondence-Redacted.PDF - Record of Conversation - Engine Overhaul Facility (item 3, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399054&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Engine%20Overhaul%20Facility-Master.PDF - Photo 1: View of the left fuel cap. (item 4, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399057&FileExtension=.PDF&FileName=Photo%201%3A%20View%20of%20the%20left%20fuel%20cap.-Master.PDF - Photo 2: View of the left fuel cap. (item 5, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399059&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20the%20left%20fuel%20cap.-Master.PDF - Photo 3: View of the left fuel cap. (item 6, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399061&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20the%20left%20fuel%20cap.-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.