# NTSB WPR18LA023: Beech B95, N9628R, Las Vegas, NV, November 3, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: November 2, 2017, 17:35 local (Nov 3, 2017, 00:35 UTC) - Place: Las Vegas, NV - Coordinates: 36.210556, -115.19444 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2106&lon=-115.1944&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 96280 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR18LA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96280/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96280 - Page: https://openairdocs.org/ntsb/WPR18LA023 ## Probable cause The flight instructor’s inadequate preflight fuel planning, which resulted in fuel exhaustion, a total loss of power to both engines, and a subsequent forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot; cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1153404), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1153404), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot; cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=1153404), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level; cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1153404), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=1153404), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=1153404), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Landing-flare/touchdown: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech B95, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=1153404), [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: [Beech B95, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1153404), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor and commercial pilot receiving instruction departed on a local instructional flight in the twin-engine airplane. The pilot receiving instruction indicated that each main fuel tank indicated about one-quarter full before departure, and the instructor stated to him that they could "run on the auxiliary tanks." The amount of fuel in the auxiliary tanks could not be recalled. After completing air work, the pilots were conducting an instrument approach to the departure airport when the left engine began to lose power. They continued the approach and shortly thereafter, the right engine also lost power. The instructor performed a forced landing to a golf course fairway, during which the airplane sustained substantial damage to the right wing and came to rest in a small lake. Examination of the airplane revealed that all of the fuel tanks were absent of fuel, and there was no evidence of fuel spillage at the accident site. Examination of the engines revealed no mechanical anomalies that would have precluded normal operation. Given the available information, it is likely that the pilots departed with an inadequate amount of fuel onboard, which resulted in fuel exhaustion and a total loss of power to both engines. ## Factual narrative On November 02, 2017, about 1735 Pacific daylight time, a Beech B95, N9628R, was substantially damaged when it was involved in an accident near Las Vegas, Nevada. The flight instructor and pilot receiving instruction sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The flight instructor reported that, before departing on the flight, the fuel quantity gauges indicated that the main fuel tanks were each about two-thirds full. He did not recall the amount of fuel in the auxiliary tanks. The pilot receiving instruction reported that, upon starting the engines before departure, the flight instructor commented, "that’s strange." When he asked, the flight instructor said the main fuel tanks were only one-quarter full. The pilot receiving instruction looked and verified that both gauges indicated about one-quarter full. He stated that the flight instructor said, "we can run on the auxiliary tanks." The pilots departed on the flight and, after performing air work, they initiated an instrument approach. About 10 miles from the airport, the left engine began to lose power. They continued the approach while the instructor attempted to troubleshoot the left engine, until about 6 miles from the airport, when the right engine began to surge, causing a "violent pitching and yawing." The instructor declared an emergency with the tower controller and subsequently chose to land on a golf course fairway. During the landing, the airplane’s right wing struck an obstacle which resulted in substantial damage to the wing. The airplane came to rest in a small lake, submerged in water. The pilots egressed from a rear window and swam to shore. Two Federal Aviation Administration inspectors responded to the accident site and noted no signs of fuel leaking and no fuel slick in the water around the airplane. Following recovery of the airplane the next day, the inspectors confirmed flight control continuity and noted that none of the fuel tanks contained fuel or water. The right main fuel bladder separated from the airplane during the accident sequence; no fuel smell was noted. The airplane was recovered to a secure storage facility for further examination. Both engines were examined, and no mechanical anomalies were noted that would have precluded normal operation. ## Aircraft - Registration: [N9628R](https://openairdocs.org/deregistered/N9628R-2020-10-03), registration cancelled 2020-10-03, S/N TD-304, built 1959 (OpenAirDocs) - Reported make and model: BEECH B95 (UNDESIGNAT) - Registry model: [Beech B95](https://openairdocs.org/model/beech-b95) (registry code 1153404) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TD-304 - Year built: 1959 - Engines: Lycoming O $ VO-360 Deries reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Departed: VGT, LAS VEGAS, NV - Destination: VGT, LAS VEGAS, NV - Airport: VGT, North Las Vegas, runway 12L, 4,199 × 75 ft, asphalt - Equipment: Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: minor; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: helicopter, airplane; medical: class 2, with waivers/limitations; seat: left; flight hours: 7,000 total - Flight instructor; injuries: minor; flight instructor, commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: basicmed, with waivers/limitations; last flight review March 16, 2017; seat: right; flight hours: 10,000 total, 7 in this make and model, 7,000 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 12 knots - Visibility: 10 statute miles - Temperature: 77 °F, dew point 37 °F - Altimeter: 29.89 inHg - Observed at: VGT, 4 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 (OpenAirDocs). - [Accident 20171102020979A](https://openairdocs.org/incident/20171102020979A), Nov 2, 2017: Beech B95, North Las Vegas, NV, Substantial damage. A Beechcraft BE-95 airplane, conducting flight training under CFR part 61, sustained substantial damage after impacting terrain approximately 3.4 miles… ## Docket (6 files) The files NTSB released with the investigation on January 27, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96280. 3.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 14 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11778358&FileExtension=pdf&FileName=NTSB%20Form%206120_Redacted-Rel.pdf - Witness statement (item 2, PDF, 1 page, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11779576&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - Statement of pilot under instruction (item 3, PDF, 3 pages, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11778071&FileExtension=pdf&FileName=Facts%20of%20airplane%20crash%20November%202,%202017%20Pilot%20under%20Instruction_Redacted-Rel.pdf - Record of email (item 4, PDF, 1 page, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11779586&FileExtension=pdf&FileName=Record%20of%20Email%20WPR18LA023-Rel.pdf - Fuel document (item 5, PDF, 1 page, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11777996&FileExtension=pdf&FileName=VGT%20Fuel%20Docs_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11778676&FileExtension=pdf&FileName=Wrecakge%20Release%20Form%20Signed_Redacted-Rel.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.