# NTSB WPR22LA349: Beech M35, N9876R, Henderson, NV, September 15, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: September 15, 2022, 12:02 local (19:02 UTC) - Place: Henderson, NV - Coordinates: 35.959887, -115.13482 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.9599&lon=-115.1348&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 105956 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22LA349 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105956/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105956 - Page: https://openairdocs.org/ntsb/WPR22LA349 ## Probable cause The flight instructor’s failure to verify the fuel quantity and improper fuel management, which resulted in fuel starvation and a total loss of engine power. ## 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 · Instructor/check pilot (probable cause); cases with it: [Beech M35, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=1151526), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Beech M35, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151526), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Beech M35, 4 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1151526), [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. - [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech M35, 3 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151526), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis The flight instructor performed a walkaround preflight inspection of the airplane and reported that he visually inspected each of the airplane’s 6 fuel tanks. He reported that the right main fuel tank was full. The flight instructor and pilot receiving instruction (the pilot) departed with the fuel selector on the left main fuel tank. After 40 minutes of flight time, the pilot selected the right main fuel tank and about 25 minutes later they noticed that the fuel quantity indicator still showed that the right tank was full. After a brief discussion they determined they had sufficient fuel to complete the trip and dismissed the abnormality. About 15 minutes later, while on short final approach, the pilot increased the airplane pitch attitude and added power, but did not receive a response from the engine, nor was there a response when he advanced the throttle to full power. The instructor selected the left main tank, but the engine did not respond, and the airplane continued to descend. The airplane impacted a berm during its subsequent forced landing and came to rest with the pilot at the controls. The right fuel tank was selected for 25 minutes during the flight and the postaccident examination revealed the fuel tank was empty while the left fuel tank, which was used for 40 minutes, was still ¾ full. The examination of the right fuel tank did not reveal any breaches in the fuel tank or fuel lines. The examination did reveal the right fuel tank fuel bladder had separated from the bottom of the fuel tank. The examination also discovered that the right main fuel tank gauge erroneously reported between ½ and ¾ full throughout the entire range of the float sensor position, consistent with the flight data and flight crew’s observations during the flight. While this evidence suggests a failure in the fuel quantity indication system, it didn’t likely contribute to the accident as the flight crew recognized the discrepancy during the flight and chose to rely on the instructor’s visual inspection of the fluid level during the preflight. The accident was the result of the instructor’s failure to verify the fuel quantity prior to departure and improper fuel management, which resulted in fuel starvation and a total loss of engine power. ## Factual narrative On September 15, 2022, about 1202 Pacific daylight time, a Beech M35 airplane, N9876R, was substantially damaged when it was involved in an accident near Henderson, Nevada. The flight instructor and pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that they planned to fly from their home airport in Camarillo, California, to satisfy an insurance requirement. The airplane was equipped with a total of 6 fuel tanks: two main fuel tanks, two auxiliary fuel tanks, and two wingtip fuel tanks. The instructor visually checked the main and auxiliary tanks by opening the fuel caps. He verified the fuel quantity of the wingtip tanks by visually observing each tanks’ window gauge. The instructor reported the following main fuel tank levels were observed during his preflight inspection (only the main fuel tanks were used during the accident flight): Fuel Tank Fuel Level Left main (25 gallons total) 3/4 Right main (25 gallons total) Full Table 1: Fuel quantities before their departure on the accident flight According to the instructor, they departed for their destination about 1005 and climbed to a cruise altitude of 7,500 ft mean sea level. The pilot, who was seated in the left seat, stated that about 40 minutes into the flight, and 45 minutes before landing, they switched to the right main fuel tank and confirmed that the fuel quantity displayed FULL on the digital fuel gauge. However, about 25 minutes later, the right main fuel gauge still indicated that the tank was FULL. The instructor and the pilot discussed the abnormality, which they attributed to a faulty sensor, but dismissed the issue after they determined that the tank contained sufficient fuel to complete the flight to their destination. About 15 minutes later, the pilot began a straight-in approach to runway 35L. While on final approach the pilot noticed the airplane’s altitude was low, so he added power but did not receive a response from the engine. The pilot then informed the instructor of the loss of altitude while he advanced the throttle to the full open position. As the pilot continued to fly the airplane, the instructor selected the left main tank on the fuel selector to restore engine power, but he was unsuccessful, and the airplane continued to descend. The airplane touched down in the dirt, impacted a berm, and came to rest on a road about 0.2 nautical miles south of the runway. Both pilots co-owned the airplane, which they had purchased together in July 2022. The airplane received substantial damage to the fuselage and left wing. A Federal Aviation Administration inspector observed the following fuel levels about one hour after the accident: Fuel Tank Fuel Level Left main (25 gallons total) 1/2 Right main (25 gallons total) Empty Table 2: Fuel quantities one hour after the accident Fuel System According to the pilot’s operating handbook, the airplane wasequipped with both main bladder fuel tanks installed at the inboard right and left wing. Outboard of the main fuel tanks are right and left wing auxiliary fuel tanks. The airplane was also equipped with right and left wingtip fuel tanks composed of fiberglass, which were installed in accordance with Federal Aviation Administration Supplemental Type Certificate SA 02722CH. The capacity of each main fuel tank is 25 gallons (22 gallons usable). Fuel is fed from both tanks to a selector valve before it continues to a fuel strainer, fuel pump and then the engine. The fuel quantity is measured by float-operated sensors that transmit electrical signals to the fuel quantity indicators on the instrument panel. Total capacity of the auxiliary tanks is 20 gallons (19 gallons usable). A postaccident examination of the fuel system found that the right main fuel tank bladder had collapsed. The inspection did not reveal any blockages in any of the fuel lines and the right main fuel tank vent was clear. When the right main fuel tank was pressurized, no leaks were observed at the fuel cap. A test of the right main fuel tank quantity measurement system found that it reported ½ - ¾ full regardless of the float sensor position in the fuel bladder. No visible breaches were observed in the right main fuel tank. JPI Data The airplane was equipped with a JPI 930 engine monitoring system. Data retrieved from the unit that captured the accident flight showed that the airplane departed about 1037, when the manifold pressure was increased to about 23 inches Hg and the engine speed was about 2,500 rpm. The right main fuel level indicated 22 gallons at the time and indicated between 18 and 22 gallons for the remainder of the flight. The left tank fuel level was about 17 gallons at the time and indicated between 8 and 12 gallons when they switched tanks about 45 minutes before their planned landing. Fuel flow was about 22 gph during cruise flight from about 1050 to 1141, at which point the fuel flow decreased to about 17 gph where it remained until the engine lost power. At 1202:26 fuel flow decreased from about 15 gph to 0 gph, accompanied by a rapid reduction in exhaust gas temperature (EGT) at each cylinder from about 1,200 – 1,400° F to about 800 – 1,000° F. During this time, manifold pressure increased to about 25 inches Hg and rpm decreased from 2,500 rpm to 1,800 rpm. In the next 30 seconds the EGTs further decreased to about 250° F, with an increase of manifold pressure to about 28 inches Hg and a decrease of engine speed to about 1,000 rpm. ## Aircraft - Registration: [N9876R](https://openairdocs.org/aircraft/N9876R), registered now, S/N D-6431, built 1960 (OpenAirDocs) - Reported make and model: BEECH M35 - Registry model: [Beech M35](https://openairdocs.org/model/beech-m35) (registry code 1151526) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-6431 - Year built: 1960 - Airframe hours: 964.6 - Engines: Continental Motors IO-550-B51 300 hp reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 20, 2022 - Departed: CMA, Camarillo, CA - Destination: Same as departure - Airport: HND, Henderson Executive, runway 35L, 6,501 × 100 ft, asphalt - Equipment: ADS-B, Auto-pilot, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: none; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 20, 2020; seat: right; restraint: 3-point; flight hours: 24,095 total, 50 in this make and model, 20,327 as pilot in command, 8 in the last 90 days, 2 in the last 30 days, 1.5 in the last 24 hours - Pilot-rated passenger; age 54; injuries: minor; commercial, military, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter; medical: class 1, without waivers/limitations; last flight review April 8, 2022; seat: left; restraint: 3-point; flight hours: 7,800 total, 1.3 in this make and model, 3,717 as pilot in command, 102 in the last 90 days, 53 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: 7,000 ft broken - Temperature: 84 °F, dew point 57 °F - Altimeter: 29.96 inHg - Observed at: KHND, 1 nm away - METAR: KHND 151856Z VRB06KT 10SM BKN070 BKN085 29/14 A2996 RMK AO2 SLP135 T02890144 ## 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 20220915017869A](https://openairdocs.org/incident/20220915017869A), Sep 15, 2022: Beech M35, Henderson, NV, Substantial damage. On September 15, 2022 beachcraft bonanza, [privacy data omitted] was approaching Henderson airport NV, (hnd) for landing. While on final at approximately 300… ## Docket (10 files) The files NTSB released with the investigation on April 25, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105956. 20.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15003904&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Accident photograph (item 2, PDF, 1 page, 788 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15799892&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf - Pilot receiving instruction information and accident statement (item 3, PDF, 4 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15003452&FileExtension=pdf&FileName=Pilot%20receiving%20instruction%20statement%20and%20crewmember%20information_Redacted-Rel.pdf - Jpi engine and fuel flow data (item 4, CSV, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15195848&FileExtension=csv&FileName=JPI%20data-Rel.csv - Fuel system excerpt from pilot's operating handbook (item 5, PDF, 5 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15196191&FileExtension=pdf&FileName=Fuel%20system%20description%20POH-Rel.pdf - Fuel system excerpt from illustrated parts catalogue (item 6, PDF, 15 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15195656&FileExtension=pdf&FileName=IPC%20Fuel%20System-Rel.pdf - Aircraft logbook excerpt (item 7, PDF, 8 pages, 7.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15195858&FileExtension=pdf&FileName=airplane%20log_Redacted-Rel.pdf - D'shannon fuel tanks supplemental type certificate documentation (item 8, PDF, 18 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15800690&FileExtension=pdf&FileName=STC%20documentation_Redacted-Rel.pdf - Fuel system inspection (item 9, PDF, 1 page, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15197706&FileExtension=pdf&FileName=N9876R%20Letter_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 2 pages, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15269991&FileExtension=pdf&FileName=Release%20of%20Wreckage_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.