WPR14LA117

NTSB accident investigation · Beech A45 · Hollister, CA · February 22, 2014

Accident · Serious injuriesLimited investigationFinal report
Date
February 22, 2014, 13:45 local (21:45 UTC)
Place
Hollister, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N666Beech A45
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report November 3, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Continental Motors Inc., Federal Aviation Administration
FAA report
20140222013879A
Case key
88827

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

On this page

Probable cause

The total loss of engine power during initial climb due to fuel starvation and the pilot’s inadequate preflight inspection and improper fuel management.

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech A45: 1 caseAll aircraft: 1,695 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotBeech A45: 2 casesAll aircraft: 551 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotBeech A45: 1 caseAll aircraft: 719 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 stated that, before the accident flight, he conducted a preflight inspection but that he did not verify the fuel level in each fuel tank. During the initial climb, the engine lost power, and the pilot then performed a 180-degree turn toward a field adjacent to the runway. About halfway through the turn, he realized that insufficient altitude existed to complete the turn, and he subsequently initiated a forced landing on a road. The airplane landed hard, which resulted in substantial damage to the fuselage and wings. Wreckage recovery personnel reported that they removed less than 2 gallons of fuel from the left wing fuel tank and more than 10 gallons of fuel from the right wing fuel tank. The fuel selector was found positioned to the left wing fuel tank. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. It is likely that the engine lost power due to fuel starvation.

Factual narrative

On February 22, 2014, about 1345 Pacific standard time, a Beech A45, N666, was substantially damaged during a forced landing following a loss of engine power during takeoff initial climb from the Hollister Municipal Airport (CVH), Hollister, California. The airplane was registered to private individuals 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, sustained serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The cross-country flight was originating at the time of the accident with an intended destination of Palo Alto, California. In a written statement to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot reported that prior to the accident flight, he had flown from Palo Alto to CVH to meet a friend and conduct a practice formation flight. During the flight to CVH, he had the left fuel tank selected. The pilot stated that following an uneventful formation flight, they returned to CVH to have lunch and debrief the flight. The pilot added that he thought he had the right fuel tank selected during the formation flight, which was over an hour in length. Following lunch, the pilot and his friend decided to perform a formation takeoff. The pilot stated that during takeoff initial climb from runway 24, the engine lost power at an altitude of about 100 to 200 feet above ground level and he decided to perform a 180-degree turn toward a planted field adjacent to the runway. About halfway through the 180-degree turn, the pilot decided he did not have enough altitude to complete the turn and leveled the wings. Subsequently, the airplane landed hard on an open road. The pilot further stated that he had the fuel selector positioned on the left fuel tank for his return flight to Palo Alto. The pilot further reported that each fuel tank held 25-gallons of fuel, which allowed for about 2 hours of flight time per fuel tank. He noted within the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1) that at the time of takeoff, he had 25 gallons of fuel on board the airplane. During a post-accident interview, the pilot stated that prior to the accident flight; he did conduct a preflight inspection on the airplane, however, did not check the fuel level in each fuel tank. Examination of the airplane by first responders revealed that the engine was partially separated and the fuselage was structurally damaged. First responders reported that they found the fuel selector valve handle positioned to the left fuel tank. The wreckage was recovered to a secure location for further examination. Examination of the recovered wreckage by the NTSB IIC revealed that both wings and right horizontal stabilizer and elevator were removed previously to facilitate transport of the wreckage. The engine remained partially attached to the airframe and was displaced downward. Throttleand mixture control continuity was established from the cockpit controls to their respective engine attach points. The fuel inlet line from the firewall was disconnected to facilitate testing of the fuel selector valve. The fuel selector valve was placed in the "left" position and compressed air was applied to the fuel inlet line at the left wing fuselage attach point. Air was felt expelling from the firewall fuel inlet line and the left wing fuel vent line. The left wing was intact and mostly undamaged. To facilitate testing the fuel tank, the fuel return line was capped off using a plastic cap. Compressed air was applied to the fuel outlet line at the wing root. Compressed air was felt expelling from the fuel drain when the drain valve was opened. No evidence of any leaks was noted. Examination of the Teledyne Continental Motors O-470-13A engine revealed that all accessories and cylinders remained attached to their respective mounts. All fuel and oil lines were intact and undamaged. The engine oil screen was removed and found to be free of debris. The crankshaft was rotated by hand using a hand tool attached to the crankshaft propeller flange. Rotational continuity was established throughout the engine and valve train and thumb compression was obtained on all six cylinders. Postaccident examination of the recovered airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The wreckage recovery company reported that during recovery of the airplane, they removed less than 2 gallons of fuel from the left wing fuel tank and in excess of 10 gallons from the right wing fuel tank.

Aircraft

Registration
N666
Reported as
Beech A45 (NO SERIES)
Category
Airplane
Serial number
GM-141
Built
1958
Airframe hours
8,800
Engine
Continental Motors O-470-13A, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
John D Forter
Registered owner
John D Forter
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 21, 2014 · 2 hours before
Departed
CVH · Hollister, CA
Destination
Palo Alto, CA
Airport
CVH · Hollister Muni, runway 24, 3,150 × 100 ft, asphalt

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
72
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
June 21, 2013
Seat
Front
Restraint
4-point
Flight hours
1,690 total · 1,000 in this make and model · 1,557 as pilot in command · 10 in the last 90 days · 3 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 15 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 46 °F
Altimeter
29.94 inHg
Observed at
KSNS, 16 nm away

Docket · 5

The files NTSB released with the investigation on June 3, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 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.