# NTSB WPR21LA342: Beech 58, N162DF, Palo Alto, CA, September 13, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: September 13, 2021, 13:40 local (20:40 UTC) - Place: Palo Alto, CA · marsh - Coordinates: 37.457391, -122.10347 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.4574&lon=-122.1035&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Wrong fuel](https://openairdocs.org/ntsb-events/194) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 103850 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21LA342 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103850/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103850 - Page: https://openairdocs.org/ntsb/WPR21LA342 ## Probable cause The fuelers addition of the incorrect fuel to the fuel tanks which resulted in a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Beech 58P, 2 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1152744), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid type (probable cause); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1152744), [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: Wrong fuel](https://openairdocs.org/ntsb-events/194) (defining event); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/194/sequence.md?model=1152744), [All aircraft, 9 cases](https://openairdocs.org/ntsb-events/194/sequence.md) - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=1152744), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech 58P, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=1152744), [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 58P, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152744), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, shortly after takeoff, about 500 ft above the ground, both engines lost power. A forced landing was subsequently initiated to an open area. During the landing, the left wing collided with a wooden post and was substantially damaged. The pilot reported that there were no preacccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The airplane was fueled before the flight. The fueler reported that he incorrectly fueled the airplane with Jet A fuel instead of Avgas. He added that he did not notice the “Avgas only” label adjacent to the fuel port, and that he did not follow the company’s fueling checklist while fueling the accident airplane. ## Aircraft - Registration: [N162DF](https://openairdocs.org/aircraft/N162DF), registered now, S/N TJ-403, built 1982 (OpenAirDocs) - Reported make and model: BEECH 58 (P) - Registry model: [Beech 58P](https://openairdocs.org/model/beech-58p) (registry code 1152744) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TJ-403 - Year built: 1982 - Airframe hours: 7500 - Engines: Continetal TSIO520WB 325 horsepower reciprocating; Continetal TSIO520WB 325 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Faford Aviation Leasing Co - Registered owner: Faford Aviation Leasing Co - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 10, 2021, 67 hours before - Destination: RNO, Reno, NV - Airport: PAO, Palo Alto - Equipment: Stall warning system, Satellite tracking device, Onboard weather, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 80; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review May 7, 2021; seat: front; restraint: 3-point; flight hours: 14,000 total, 6,500 in this make and model, 14,000 as pilot in command, 50 in the last 90 days, 15 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 59 °F - Altimeter: 29.87 inHg - Observed at: KPAO, 1 nm away - METAR: KPAO 132047Z 33010KT 10SM SKC 24/15 A2987 ## 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 20210913022099A](https://openairdocs.org/incident/20210913022099A), Sep 13, 2021: Beech 58P, Palo Alto, CA, Substantial damage. Palo Alto, CA (pao): N162DF, BE58, pao -rno , crashed approx 1 mile NE of arpt in marsh area, struck high power voltage line, transported to local hospital w/… ## Docket (5 files) The files NTSB released with the investigation on January 25, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103850. 8.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13050424&FileExtension=pdf&FileName=6120%20342_Redacted-Rel.pdf - Record of conversation - fueler (item 2, PDF, 1 page, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13050514&FileExtension=pdf&FileName=RECORD%20OF%20CONVERSATION%20Fueler%20342-Rel.pdf - Record of conversation - pilot (item 3, PDF, 1 page, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13049649&FileExtension=pdf&FileName=RECORD%20OF%20CONVERSATION%20-%20Pilot%20342-Rel.pdf - Fueling logbook entry on day of accident (item 4, PDF, 1 page, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13151376&FileExtension=pdf&FileName=Item%201%20Fueling%20Logbook%20Entry-Rel.pdf - Accident photos (item 5, PDF, 2 pages, 829 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13049929&FileExtension=pdf&FileName=Accident%20Photo%20342-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.