N1456L

Substantial
Serious

Beech A23S/N: M-842

Accident Details

Date
Wednesday, August 3, 2005
NTSB Number
LAX05LA258
Location
Rancho Murieta, CA
Event ID
20050811X01223
Coordinates
38.486667, -121.102775
Aircraft Damage
Substantial
Highest Injury
Serious
Fatalities
0
Serious Injuries
2
Minor Injuries
0
Uninjured
1
Total Aboard
3

Probable Cause and Findings

fuel starvation due to the inadequate fuel system management by both pilots. Also causal was the inadequate preflight inspection by both the instructor and student and their failure to verify the fuel quantities in each fuel tank, and, the instructor's inadequate supervision of the flight.

Aircraft Information

Registration
N1456L
Make
BEECH
Serial Number
M-842
Engine Type
Reciprocating
Year Built
1965
Model / ICAO
A23BE23
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
MASON ALLEN L
Address
1740 FOOTHILL RD
Status
Deregistered
City
GARDNERVILLE
State / Zip Code
NV 89410-6210
Country
United States

Analysis

HISTORY OF FLIGHT

On August 3, 2005, about 0910 Pacific daylight time, a Beech Musketeer A23, N1456L, collided with terrain about 1/4 mile short of the runway at Rancho Murieta Airport, Rancho Murieta, California. Rancho Rotors was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) and student pilot sustained serious injuries and the passenger was uninjured. The airplane sustained substantial damage. The instructional flight departed Eagle's Nest Airport, Ione, California, with a planned destination of Rancho Murieta. Visual meteorological conditions prevailed, and a flight plan had not been filed.

In a written statement, the Federal Aviation Administration (FAA) inspector stated that the accident flight originated from Eagle's Nest, located about 6 nautical miles (nm) from Rancho Murieta. The flight was intended to be a training flight and the student pilot was positioned in the left seat. As the airplane approached Rancho Murieta, the student pilot configured the airplane for landing on runway 22. While on the base leg of the traffic pattern, the engine experienced a loss of power. The airplane impacted terrain about 1/4 mile to the east of the runway, coming to rest upright on a riverbank.

The FAA inspector further stated that the airplane wreckage was located about 20 degrees to the south of runway 22, with the nose oriented on northeast heading. The right wing appeared to have collided with a large clump of river willows. He noted minor damage on the leading edge. The right wing fuel tank had partially separated from the wing and a minor tear was visible on top of the wing, aft of the fuel tank (adjacent to the landing gear attachment points). An examination of the right fuel tank revealed it was empty. The FAA inspector could not find any evidence that the right fuel tank had been breached and noted no perforations. There was minor damage to the left wing. The left fuel tank was full with fuel. The fuel selector valve was positioned on the right tank.

Fire department personnel reported that upon arrival at the accident scene there had been a slight odor resembling fuel. According to the FAA inspector, they did not move the fuel selector.

The student pilot's father reported to the FAA inspector that he had spoken to his daughter after the accident while she was in the hospital. She stated that the night before the accident she and the CFI conducted a 59 nm night flight from Rancho Murieta to Colusa Country Airport, Colusa, California. They arrived at the airport, but departed shortly thereafter for a 64 nm flight to Eagle's Nest where they spent the night.

The student pilot further told her father that while conducting a preflight inspection of the airplane at Eagle's Nest, prior to departing on the accident flight, the CFI asked her to put some items in the baggage compartment. She did not check the airplane's fuel quantity and could not recall if the CFI had finished the preflight inspection.

The engine quit while on the base leg of the approach for runway 22, and the CFI took over the flight controls. The student pilot remembered pointing out a field that was in close proximity, but the CFI continued in the direction of the airport. The student pilot did not recall the CFI manipulating the fuel selector or turning the fuel pump on.

While conducting an examination of the airplane, the National Transportation Safety Board investigator found a notebook in the wreckage amongst the cockpit debris. On the first page of the notebook was a list of five items: "right fuel gauge, EGT gauge, cabin air cable-lube, front strut bushing, grease landing gear, throttle cable walks."

PERSONNEL INFORMATION

According to the FAA airman and medical records, the instructor held a certified flight instructor certificate with an airplane rating for single engine land. She additionally held a commercial certificate with ratings for airplane single engine land and instrument flight, as well as a private pilot certificate with a rating for multiengine land airplanes. The pilot was issued a second-class medical certificate on January 20, 2005, with no limitations.

Despite numerous attempts, Safety Board investigators were unable to obtain a copy of the CFI's personal logbooks. She failed to file or return a Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2.

AIRCRAFT INFORMATION

The airplane was a Beech A23, serial number M-842, which was manufactured in 1965. According to the maintenance records, the airframe had accumulated a total time in service of 2,530.5 hours. The most recent annual inspection of the airframe and engine was completed on July 5, 2005, about 47 hours prior to the accident. The FAA airworthiness inspector compared the Airworthiness Directive (AD) compliance list in the logbook against a list of AD's applicable to the aircraft's serial number. He stated that all AD's had been endorsed as being complied with.

Fuel System

The Musketeer A23 Pilot's Operating Handbook contains a narrative and pictorial depiction of the fuel system in Section VII, Systems Description. It states that the fuel tanks are located in both the left and right wing near the inboard leading edge. They each have a capacity of 29.9 gallons, for a total capacity of 59.8 gallons, and a useable fuel quantity of 52.2 gallons. It indicates that the pilot must visually check the fuel level in each wing tank during the preflight inspection in an effort to ascertain the desired quantity.

The fuel system is designed for the fuel to flow from the desired wing tank to the fuel selector valve, where it is routed through a strainer to the engine driven fuel pump. A fuel return line is located at the engine driven fuel pump, which serves as a means to route approximately 3 to 6 gallons per hour of excess fuel to the left tank (occurs when the engine is operating at 75 percent power or less).

The fuel quantity is measured by a float-operated sensor located in each wing tank, which electrically transmits an indication of fuel remaining to the respective fuel gauge. The indicators will display a full fuel indication when 20 or more gallons are in the tank.

The manual further states that the fuel selector valve handle, located on the floorboards between the front seats, should be selected to the fullest tank during takeoff and landings. A caution is given stating "Use 15 gallons from the left tank first." The manual indicates that it is the pilot's responsibility to ascertain that the fuel quantity indicators are functioning and maintaining a reasonable degree of accuracy, and to be certain of ample fuel for flight. It further states that takeoff is prohibited with less than 11 gallons in each tank.

TESTS AND RESEARCH

Following recovery, the airplane was examined under the supervision of a Safety Board investigator at the storage facility of Plain Parts, Pleasant Grove, California. An FAA inspector and a representative of Teledyne Continental Motors were present at the examination.

The airplane was separated into four major components for the purpose of recovery. The wreckage consisted of the left and right wing, fuselage (with the engine attached at the mounts), and empennage. Recovery personnel detached both wings from the fuselage at their respective inboard root, leaving the fuel sending unit wires exposed. They also cut and marked flight control cables. The empennage was separated near the aft baggage bulkhead, just behind the battery.

Investigators established flight control continuity from where the cables started at the empennage section to the elevator and rudder surfaces. Flight control continuity could not be established to the aileron cables or the elevator and rudder cables forward of the empennage due to the crush deformation of the cabin area. The wing flaps were in the retracted position. The landing gear handle was in the extended position, and the FAA inspector stated that by looking at the nose landing gear attachment, the landing gear appeared to be in the extended position at the time of impact.

The Continental IO-346 engine, serial number 100466-6-A, remained intact. It had incurred visible external damage consisting of an upward crushing to the muffler and connected exhaust stacks, as well as a puncture in the oil pan. Oil coated the muffler area adjacent to the puncture in the oil pan. With use of the dipstick, investigators determined the engine contained less than a quart of oil in the crankcase.

The mixture arm and throttle arm were fully forward, an indication that the airplane was configured in the full rich, maximum power position. Continuity was established for both the throttle and mixture control cables.

The fuel manifold was dissembled and about a teaspoon of fluid was found in the cavity; the fuel screen was clean with no debris present. The gascolator was clean and no remnant of fluid was found. Investigators disconnected the fuel line from the number four cylinder, providing air pressure to one end of the line; a blue liquid resembling avgas departed the other end of the line. A spark plug from each cylinder was removed; no mechanical damage was noted and the electrodes and posts exhibited a light ash gray coloration, which the FAA inspector said was consistent to normal wear and operation.

In order to check for leaks and facilitate an engine run-up, investigators attempted to seal the hole in the oil pan with an adhesive. They additionally sawed the exhaust stacks, shortening each pipe. Oil was added to the engine and a club propeller was attached to the propeller flange. In an effort to assess the fuel line continuity, investigators filled the header tank with a gallon of fuel, and did not observe any external secretion of fluid throughout the length of the line.

Investigators strapped the airplane to a trailer and the Continental engine representative posi...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX05LA258