# NTSB WPR15LA167: Beech F33A, N84MD, Puyallup, WA, April 18, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 18, 2015, 11:00 local (18:00 UTC) - Place: Puyallup, WA - Coordinates: 47.102222, -122.285552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.1022&lon=-122.2856&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 14, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Continental Motors Inc, Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 91230 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA167 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91230/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91230 - Page: https://openairdocs.org/ntsb/WPR15LA167 ## Probable cause A total loss of engine power due to fuel starvation as a result of a mechanic’s failure to properly tighten the B-nut to the fuel pump inlet during a recent annual inspection. Contributing to the accident was the pilot's decision to take off despite indications that the engine was not operating normally. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [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: [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. - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [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: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The private pilot was conducting the airplane's first flight after an annual inspection. On the morning of the accident, the pilot picked up the airplane and conducted a run-up, during which the engine lost power. The airplane was towed back to the maintenance shop, and a mechanic recommended that the pilot wait until a more detailed examination could be completed. The pilot downloaded the data from the airplane's engine data monitor and took it home to examine. After returning to the airport later that day, the pilot reported to the mechanic that he did not observe anything abnormal in the data, and he got back in the airplane to depart for the accident flight. The pilot reported that, about 350 ft above the ground during initial climb, the engine lost power with no abnormal noises or sounds, and he landed in a field. The airplane subsequently rolled down an embankment, the nosewheel collapsed, and the airplane then came to rest. During a postaccident engine run, the airplane started without hesitation; however, it lost power after the fuel boost pump was turned off. Further examination revealed that the B-nut to the fuel pump inlet was loose. The B-nut was tightened, and the engine then started and operated up to about 2,100 rpm with no additional anomalies. Data from the engine's data management system were analyzed, and the data revealed seven separate data sessions on the day of the accident, six leading up to the accident session. Based on the evidence, it is likely that the mechanic did not properly tighten the B-nut to the fuel pump inlet during the annual inspection and that the loose B-nut at the fuel pump resulted in the airplane being starved of fuel without the assistance of the pump. The accident likely would have been avoided if the pilot had not attempted to take off with indications that the airplane was not operating normally. ## Factual narrative On April 18, 2015 about 1100 Pacific daylight time, a Beech F33A, N84MD, experienced a total loss of engine power shortly after takeoff from Pierce County Airport – Thun Field (PLU) in Puyallup, Washington. The pilot (sole occupant) sustained no injuries, and the airplane sustained substantial damage to the engine mounting structure. The airplane was registered to, and operated by, the pilot under provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The pilot reported that after an uneventful run-up he took off from the runway. About 350 feet above the ground the engine stopped. There were no abnormal sounds, but instead it sounded as if the mixture had been pulled to cut off. The pilot found a safe place to land and landed in a field. The airplane rolled in the field and down an embankment before the nose wheel collapsed and the airplane came to rest nose down. A mechanic reported that this was the first flight after an annual inspection dated April 17, 2015. The morning of the accident, the pilot came to pick up the airplane; he filled it with fuel and taxied toward the runway. The pilot was conducting a run-up when the engine died. The airplane was towed back to the maintenance shop and a mechanic visually inspected, and ran, the engine. Since nothing was found the mechanic suggested the pilot wait until Monday to have it further examined. The pilot downloaded the data from the airplane's engine data monitor and took it home to examine. Later that day the pilot returned to the airport and he informed the mechanic he found nothing abnormal on the data. The pilot got back into the airplane and taxied it to the runway. A different mechanic observed the pilot conduct a few high speed taxi tests before he took off. After the takeoff, about 200 feet above the ground, the engine lost power and the airplane glided to a field. After a postaccident external examination and the installation of an undamaged propeller, an engine run was performed. The engine started without hesitation, however, when the fuel boost pump was turned off the engine shut down shortly thereafter. Upon further examination, the B-nut to the fuel pump inlet was noted to be loose. The fuel line B-nut was tightened and another engine run was attempted. The engine started and it operated normally, even after the boost pump was turned off. The engine was run for about five minutes and the engine RPM was slowly increased to about 2,100 RPM. All engine gauges indicated normal operation. The airplane's engine data management system was removed from the airframe and sent to the National Transportation Safety Board Recorders Laboratory. On the day of the accident there were seven sessions of data recorded. The accident sequence occurred during the seventh session. The first six sessions occurred during a time span of about 1 hour and 18 minutes. There was an about 1 hour and 14minutes break between the sixth and seventh sessions. The data revealed that during the seventh session, the engine speed was increased to mid power for approximately one minute. About 2 minutes later the engine RPM was increased to 2,727 RPM followed by 2,462 RPM, 6 seconds later. The engine speed briefly increased to 2,628 for 12 seconds before falling below 1,000 RPM. ## Aircraft - Registration: N84MD (not matched to a registry record) - Reported make and model: BEECH F33A - Category: Airplane - Serial number: CE577 - Year built: 1975 - Airframe hours: 4474 - Engines: Continental Motors IO 520 SERIES 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Clark Daniel W - Registered owner: Clark Daniel W - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 17, 2015, 0 hours before - Departed: PLU, Puyallup, WA - Destination: PLU, Puyallup, WA - Airport: PLU, Pierce County Airport - Thun F, runway 34, 3,650 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review August 12, 2014; seat: left; restraint: lap only; flight hours: 284 total, 120 in this make and model, 214 as pilot in command, 9 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 43 °F - Altimeter: 30.35 inHg - Observed at: KPLU ## 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 20150418006739A](https://openairdocs.org/incident/20150418006739A), Apr 18, 2015: Beech F33A, Puyallup, WA, Substantial damage. N84MD landed off airport just north of Pierce county airport (kplu) when the engine stopped producing power. N84MD had been in and out of maintenance the… ## Docket (12 files) The files NTSB released with the investigation on July 6, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91230. 8.1 MB in all. - Engine Data Monitor Factual Report (item 1, .PDF, 7 photos, 598 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442054&FileExtension=.PDF&FileName=Engine%20Data%20Monitor%20Factual%20Report-Master.PDF - Engine Data Monitor Factual Report - Attachment 1 (item 2, .CSV, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442055&FileExtension=.csv&FileName=Engine%20Data%20Monitor%20Factual%20Report%20-%20Attachment%201-Master.csv - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 3, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442056&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - FAA Inspectors Regarding Mechanic Statement (item 4, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442057&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspectors%20Regarding%20Mechanic%20Statement-Master.PDF - Airframe and Engine Examination (item 5, .PDF, 9 photos, 692 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442058&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Examination-Master.PDF - Maintenance Records (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442059&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Reports from Parties to the Investigation - Continental Motors (item 7, .PDF, 12 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442060&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Continental%20Motors-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442061&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442062&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Evidence Control Form - Engine Data Monitor (item 10, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442063&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20-%20Engine%20Data%20Monitor-Master.PDF - On Scene Photos Courtesy of Law Enforcement (item 11, .PDF, 3 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442064&FileExtension=.PDF&FileName=On%20Scene%20Photos%20Courtesy%20of%20Law%20Enforcement-Master.PDF - Video of Engine Run - Loose B-Nut (item 12, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442065&FileExtension=.PDF&FileName=Video%20of%20Engine%20Run%20-%20Loose%20B-Nut-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.