# NTSB WPR19LA265: Beech 35, N5277C, Gresham, OR, September 24, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 23, 2019, 17:54 local (Sep 24, 2019, 00:54 UTC) - Place: Gresham, OR - Coordinates: 45.470001, -122.470001 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.4700&lon=-122.4700&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 100317 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA265 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100317/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100317 - Page: https://openairdocs.org/ntsb/WPR19LA265 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech B35, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151506), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Beech B35, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=1151506), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Beech B35, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151506), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech B35, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151506), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech B35, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151506), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N5277C-2021-07-30), registration cancelled 2021-07-30, S/N D-2671, built 1951 (OpenAirDocs) - Reported make and model: Beech 35 (B35) - Registry model: [Beech B35](https://openairdocs.org/model/beech-b35) (registry code 1151506) (OpenAirDocs) - Registry engine: [Continental E225 series](https://openairdocs.org/engine/continental-e225-series) (registry code 17015, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-2671 - Year built: 1951 - Airframe hours: 5164 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 25; injuries: serious; 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 - 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 ## 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 20190923013589A](https://openairdocs.org/incident/20190923013589A), Sep 23, 2019: Beech B35, Gresham, OR, Substantial damage. N5277C had not been flown in two or three weeks per the aircraft owner. When the owner and a CFI attempted to start the engine, it wouldn'tt start and required… ## Docket (10 files) The files NTSB released with the investigation on May 5, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100317. 3.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 753 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12580288&FileExtension=pdf&FileName=NTSB%206120-1_Redacted-Rel.pdf - Student pilot/owner statement (item 2, PDF, 2 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581551&FileExtension=pdf&FileName=Record%20of%20telcon_Michelsen%20-%2009-25-19%201_Redacted-Rel.pdf - CFI response to questions (item 3, PDF, 4 pages, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13795084&FileExtension=pdf&FileName=Re%20N5277C%20Accident%20in%20Gresham_3%20CFI%20QUESTION%20Responses_Redacted-Rel.pdf - Record of email (item 4, PDF, 3 pages, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581292&FileExtension=pdf&FileName=Record%20of%20Email%20WPR19LA265%20Fiinal%201-Rel.pdf - POH excerpt (item 5, PDF, 1 page, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581442&FileExtension=pdf&FileName=POH%20Excerpt-Rel.pdf - N5277C flightaware track (item 6, PDF, 2 pages, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12582110&FileExtension=pdf&FileName=N5277C_FlightAware-Rel.pdf - Individual who jump started airplane (item 7, PDF, 1 page, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581705&FileExtension=pdf&FileName=Record%20of%20Telcon_Trulin%20-%2009-24-19%202_Redacted-Rel.pdf - Refueler statement (item 8, PDF, 1 page, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581165&FileExtension=pdf&FileName=Refueler%20Warren_Statement%20-%2009-26-19_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 1 page, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581931&FileExtension=pdf&FileName=NTSB%20Wreckage%20Release%201_Redacted-Rel.pdf - Accident pictures (item 10, PDF, 3 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12581531&FileExtension=pdf&FileName=WPR19LA265%20Accident%20Pictures_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.