WPR16CA145

NTSB accident investigation · Beech 19A · Helena, MT · July 18, 2016

Accident · Minor injuriesData collectionFinal report
Date
July 18, 2016, 08:00 local (14:00 UTC)
Place
Helena, MT
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N7645RBeech 19A
Defining event
Takeoff: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report September 12, 2016
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA HLN FSDO
FAA report
20160718020159A
Case key
93622

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 pilot's failure to reposition the fuel selector valve to the on position prior to takeoff resulting in a loss of engine power due to fuel starvation. Contributing to the accident was the pilot's failure to properly complete the pre-takeoff checklist.

Findings · 5

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.

Action: forgotten action/omissionPersonnel issues › Action/decision · PilotBeech 19A: 1 caseAll aircraft: 440 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationBeech 19A: 2 casesAll aircraft: 176 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech 19A: 2 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech 19A: 1 caseAll aircraft: 1,391 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotBeech 19A: 1 caseAll aircraft: 336 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 the initial climb after takeoff, about 500 feet, the engine lost power. He made a left turn to return to the airport, but instead touched down hard next to the runway. The airplane sustained substantial damage to the left wing. This was the first flight following completion of an annual inspection. During the inspection maintenance personnel had placed the fuel selector valve (FSV) in the off position, and did not return it to the full on position before the flight. The pilot reported that he and the owner usually kept the fuel selector valve in the on position, and that he did not use a checklist or confirm that it was in the full on position before takeoff.

Factual narrative

The pilot reported that during the initial climb after takeoff, about 500 feet, the engine lost power. He made a left turn to return to the airport, but instead touched down hard next to the runway. The airplane sustained substantial damage to the left wing. This was the first flight following completion of an annual inspection. During the inspection maintenance personnel had placed the fuel selector valve (FSV) in the off position, and did not return it to the full on position before the flight. The pilot reported that he and the owner usually kept the fuel selector valve in the on position, and that he did not use a checklist or confirm that it was in the full on position before takeoff.

Aircraft

Registration
N7645R
Reported as
Beech 19A
Category
Airplane
Serial number
MB-436
Built
1969
Engine
Lycoming IO360 A1A, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 22, 2016
Departed
HLN · Helena, MT
Destination
38S · Deer Lodge, MT
Airport
HLN · Helena, runway 35, 2,989 × 75 ft, asphalt
Equipment
Unknown

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
68
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
5,000 total · 500 in this make and model · 5,000 as pilot in command · 25 in the last 90 days · 10 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 3 knots
Visibility
10 statute miles
Temperature
64 °F, dew point 52 °F
Altimeter
30.07 inHg
Icing
Unknown
Turbulence
Unknown
Observed at
KHLN

Docket · 2

The files NTSB released with the investigation on August 30, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 812 KB 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.