WPR18FA266

NTSB accident investigation · Beech 33 · Cottonwood, AZ · September 17, 2018

Accident · FatalClass 2 · FieldFinal report
Date
September 17, 2018, 09:45 local (16:45 UTC)
Place
Cottonwood, AZ
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2031DBeech 33
Defining event
Approach: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Western Pacific Region
Parties
FAA-FSDO, Continental Motors, Textron Aviation
FAA report
20180917016339A
Case key
98317

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 mismanagement of the available fuel, which resulted in a total loss of engine power due to fuel starvation.

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.

Action: lack of actionPersonnel issues › Action/decision · PilotBeech F33A: 2 casesAll aircraft: 792 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech F33A: 6 casesAll aircraft: 1,391 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech F33A: 4 casesAll aircraft: 1,695 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 owner of the airplane and the pilot completed a cross-country flight; upon landing, the owner disembarked and the pilot departed alone on the return flight. Radar data showed that the airplane entered the traffic pattern at the origination airport at the conclusion of the return flight and, after turning onto the final leg of the traffic pattern for landing, the airplane continued to descend and impacted the roof of a home about 1/4 mile from the approach end of the runway. A witness who responded to the site immediately after the accident stated that the pilot said "something about an engine problem." The left wing and fuel tank were mostly intact; the tank contained trace amounts of fuel. The inboard right wing, including the fuel tank, was mostly consumed by a postcrash fire. The fuel selector was found in the right tank position. Postaccident examination of the airplane and test run of the engine revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The owner of the airplane stated that they departed on the first leg of the flight with the airplane fueled to capacity. About 30 minutes into the flight, they switched the fuel selector from the right tank to the left tank. Fuel consumption information from the airplane's Pilots Operating Handbook indicated that, if the airplane flew the remainder of the first leg of the flight and the entire return flight with the left fuel tank selected, the fuel consumed would have been about equal to the usable fuel available in that tank. Given the lack of fuel found in the intact left main tank, the lack of mechanical anomalies found during examination, and the pilot's report of engine problems, it is likely that the pilot failed to switch the fuel selector during the return flight, which resulted in fuel starvation and a total loss of engine power. It is possible that the pilot switched fuel tanks following the loss of power but that the airplane's low altitude at the time of the power loss provided inadequate time to restore fuel flow and engine power before the airplane impacted the ground.

Factual narrative

Narrative additional information place holder The Pilot's Operating Handbook (POH) for the airplane stated that the total fuel capacity was 80 gallons, of which 74 gallons of fuel were useable. The owner stated that whenever he refueled his airplane, he would fill the tanks to about an inch below the top of the tank. Based on the fuel consumption information from the POH, the airplane would have consumed about 32 gallons of fuel after the pilots switched from the right to left tank during the first leg of the flight. Narrative airport information place holder Narrative communications place holder Narrative damage to aircraft place holder Narrative fire place holder Narrative flight recorders place holder On September 17, 2018, about 0945 mountain standard time, a Beech F33A airplane, N2031D, was substantially damaged when it was involved in an accident near Cottonwood, Arizona. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The owner of the airplane stated that he and the pilot flew from Cottonwood Airport (P52), Cottonwood, Arizona, to North Las Vegas Airport (VGT), Las Vegas, Nevada. The airplane was fueled to capacity 2 days before the flight and was not flown until the day of the accident. The owner estimated that the airplane could fly 6.5 hours of total flight time with that amount of fuel and stated that the ForeFlight application estimated a flight time of 1 hour 10 minutes between P52 and VGT. A preflight inspection of the airplane revealed no anomalies, and the pilots departed on the flight to VGT. About 30 minutes into the flight, they switched from the right fuel tank to the left tank. The flight was uneventful, and the owner was very confident in the pilot's control of the airplane. He stated that the right wing tank was about 1/2 full and the left wing tank was about 3/4 full when they landed. After landing at VGT, the owner disembarked the airplane with the engine still running. The owner then drove back to Cottonwood, and the pilot embarked alone on the return flight. Radar data showed that, as the airplane approached P52, it entered a right downwind leg for runway 32. The airplane made a right turn for the base leg for runway 32 and began to descend, then continued its descent as it turned toward the runway; the last radar returns were low to the ground and near the accident site. (See Figure 1.) The airplane impacted a house and cartwheeled into the backyard. Figure 1-Radar flight track data and the accident site location. According to a witness who responded to the accident, the pilot had initially survived the accident and reported, "something about an engine problem." Based on radar data, the airplane's total flight time on the day of the accident was about 2 hours 33 minutes. Narrative injuries to persons place holder According to the autopsy performed by the Maricopa County Office of the Medical Examiner, the cause of death was complications ofthermal burns. The pilot initially survived, but succumbed to his injuries several hours after the accident. Toxicology testing performed by the Federal Aviation Administration's Forensic Science Laboratory on blood obtained at autopsy identified several medications consistent with postaccident emergency medical interventions, as well as cetirizine in cardiac blood (0.129 ug/ml) and liver. Cetirizine is a sedating antihistamine commonly available with the name Zyrtec. Narrative meteorological information place holder Narrative organizational and management information place holder Narrative other damage place holder The pilot's logbook was not recovered. The owner reported that the pilot had not flown the accident airplane before the day of the accident. Narrative survival aspects place holder Narrative tests and research place holder Narrative useful or effective investigation techniques place holder The airplane impacted the roof of a home about 1/4 mile from the approach end of runway 32. The airplane subsequently impacted a tree and a bush before impacting the ground in the backyard of the home. The airplane came to rest in the opposite direction of the debris field. The right wing exhibited leading edge impact damage, and the right wing inboard section and cabin area was mostly consumed by postimpact fire. The left wing was mostly intact and trace amounts of fuel from the left wing tank were collected during the recovery of the wreckage. The examination of the engine and airframe revealed no evidence of preimpact malfunctions or anomalies. The left wing fuel tank was intact and undamaged. The fuel selector valve was found in the right tank position. A test run of the engine revealed no anomalies.

Aircraft

Registration
N2031D
Reported as
Beech 33 (F33A)
Category
Airplane
Serial number
CE-809
Built
1978
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Departed
VGT · Las Vegas, NV
Destination
P52 · Cottonwood, AZ
Airport
P52 · Cottonwood, runway 32, 4,252 × 75 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
70
Injuries
Fatal
Certificates
Airline transport, Commercial
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
10,854 total · 99 in this make and model · 12 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 46 °F
Altimeter
30.12 inHg
Observed at
KSEZ, 14 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.