# NTSB WPR16CA145: Beech 19A, N7645R, Helena, MT, July 18, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: July 18, 2016, 08:00 local (14:00 UTC) - Place: Helena, MT - Coordinates: 46.606945, -111.98278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.6069&lon=-111.9828&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report September 12, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA HLN FSDO - NTSB case key (mKey): 93622 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16CA145 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93622/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93622 - Page: https://openairdocs.org/ntsb/WPR16CA145 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 19A, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=1151214), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech 19A, 2 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=1151214), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech 19A, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151214), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 19A, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151214), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech 19A, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1151214), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech 19A, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151214), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Beech 19A, 1 case](https://openairdocs.org/ntsb-events/092/sequence.md?model=1151214), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## 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](https://openairdocs.org/deregistered/N7645R-2019-01-09), registration cancelled 2019-01-09, S/N MB-436, built 1969 (OpenAirDocs) - Reported make and model: BEECH 19A - Registry model: [Beech 19A](https://openairdocs.org/model/beech-19a) (registry code 1151214) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MB-436 - Year built: 1969 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: minor; 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 ## 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 20160718020159A](https://openairdocs.org/incident/20160718020159A), Jul 18, 2016: Beech 19A, Helena, MT, Substantial damage. N7645R requested a VFR departure to the west. N7645R was assigned runway 35 for departure and given taxi instructions to the runway via taxiway c. N7645R was… ## Docket (2 files) The files NTSB released with the investigation on August 30, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93622. 812 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 754 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443996&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector Statement (item 2, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443997&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-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.