WPR19LA265

NTSB accident investigation · Beech 35 · Gresham, OR · September 24, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
September 23, 2019, 17:54 local (Sep 24, 2019, 00:54 UTC)
Place
Gresham, OR
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5277CBeech 35
Defining event
Enroute: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20190923013589A
Case key
100317

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

A total loss of engine power due to fuel starvation as a result of the instructor’s inadequate in-flight fuel management.

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementBeech B35: 2 casesAll aircraft: 1,695 casesProbable cause
Attention/monitoring: monitoring equip/instrumentsPersonnel issues › Psychological · Instructor/check pilotBeech B35: 1 caseAll aircraft: 142 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotBeech B35: 2 casesAll aircraft: 1,391 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

Before departing on an approximate 1 hour and 20-minute instructional flight, the instructor and student idled on the airplane on the ground for about 30 minutes. While conducting maneuvers, the engine “audibly slowed down drastically” and the propeller and throttle controls did not respond to pilot inputs. The instructor performed a forced landing to a field, resulting in substantial damage. Examination of the wreckage revealed that the right main fuel tank was intact and void of fuel. The left main fuel tank was full. The fuel selector was found in the right main tank position and the selector valve operated normally after the accident. Based on the available information, it is likely that the entirety of the flight was conducted with the right main fuel tank selected, which resulted in fuel starvation and a total loss of engine power.

Factual narrative

On September 23, 2019, about 1754 Pacific daylight time, a Beech B35 airplane, N5277C, was substantially damaged when it was involved in an accident near Portland, Oregon. The flight instructor and the student pilot were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The flight instructor stated that the airplane was serviced to capacity with 24 gallons of fuel before the flight. The individual who refueled the airplane confirmed that he added fuel “to the bottom of the fuel caps.” A mechanic who had assisted starting the accident airplane before the flight stated that the airplane held short of the runway running its engine for about 30 minutes before taking off. The instructor stated that, while practicing maneuvers, the engine speed increased as though the propeller control had been moved full forward; shortly thereafter, the engine “audibly slowed down drastically.” The instructor stated that they cycled the propeller control and adjusted the throttle, but neither had any effect. The instructor subsequently performed a forced landing to a small field. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the left-wing tank was full, and the right-wing tank was empty. The fuel selector was positioned to the right fuel tank. After the airplane was recovered, the FAA inspector examined the airplane again and stated that the right fuel tank appeared intact. The fuel selector operated normally when each detent was selected. Flight tracking data from a commercially available website indicated that the accident flight was about 1 hour and 19 minutes in duration. According to the Beech B35 Pilot's Operating Handbook (POH), each main fuel tank held about 17 gallons of usable fuel.

Aircraft

Registration
N5277C
Reported as
Beech 35 (B35)
Category
Airplane
Serial number
D-2671
Built
1951
Airframe hours
5,164
Engine
Continental E-225-8-20, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2019
Departed
SPB · Scappoose, OR
Destination
SPB · Scappoose, OR
Equipment
None

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
25
Injuries
Serious
Certificates
Commercial, Flight instructor
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
October 10, 2018
Seat
Right
Restraint
Lap only
Flight hours
1,115.6 total · 3 in this make and model · 917 as pilot in command · 244 in the last 90 days · 17 in the last 30 days
Role
Student pilot
Age
42
Injuries
Serious
Seat
Left
Restraint
Lap only
Flight hours
0 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
5,500 ft overcast
Temperature
68 °F, dew point 48 °F
Altimeter
30.21 inHg
Observed at
TTD, 5 nm away

Docket · 10

The files NTSB released with the investigation on May 5, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.6 MB 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.