N293GC

Substantial
Fatal

BEECH 35C33S/N: CD-1035

Accident Details

Date
Tuesday, October 31, 2017
NTSB Number
ERA18FA012
Location
Whiteville, NC
Event ID
20171031X10138
Coordinates
34.263889, -78.726943
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
0
Minor Injuries
1
Uninjured
0
Total Aboard
2

Probable Cause and Findings

The pilot's mismanagement of the available fuel, which resulted in a total loss of engine power due to fuel starvation, and his delayed reaction to the loss of engine power, which led to impact with trees as he was attempting to switch fuel tanks. Contributing to the accident was pilot's decision to operate the airplane with a malfunctioning fuel quantity indication system.

Aircraft Information

Registration
N293GC
Make
BEECH
Serial Number
CD-1035
Engine Type
Reciprocating
Year Built
1966
Model / ICAO
35C33BE33
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
CHARTRESS GEORGE H
Address
12 MAPLE CT
Status
Deregistered
City
WATERFORD
State / Zip Code
CT 06385-4326
Country
United States

Analysis

HISTORY OF FLIGHTOn October 31, 2017, about 1002 eastern daylight time, a Beech 35-C33 airplane, N293GC, was substantially damaged when it was involved in an accident near Whiteville, North Carolina. The pilot was fatally injured, and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to the pilot-rated passenger, the pilot had initially intended to fly from Cannon Creek Airport (15FL), Lake City, Florida, to Lake City Gateway Airport (LCQ), Lake City, Florida, for fuel, but the fixed-base-operator there was closed, so they decided to refuel at Columbus County Municipal Airport (CPC), Whiteville, North Carolina, and then at Leesburg Executive Airport (JYO), Leesburg, Virginia, on their way to their final destination of Westerly State Airport (WST), Westerly, Rhode Island.

The pilot-rated passenger stated that, on the morning of the accident, during the preflight inspection of the airplane, he and the pilot noticed that the fuel level was about 1/2 inch above the tabs in both fuel tanks; the pilot told the passenger that the airplane's engine would consume about 11.5 gallons per hour in cruise flight. After departing 15FL, they flew with the fuel selector in the right tank position for 1 hour 25 minutes. When they were about 40 minutes from CPC, the pilot switched the fuel selector to the left tank position.

The pilot-rated passenger stated that, during the final approach to runway 6 at CPC, when the airplane was about 700 ft mean sea level , the pilot switched the fuel selector to the right tank, as the landing checklist required the selector to be selected to the fullest tank for approach and landing. The pilot-rated passenger noticed that the left fuel tank gauge was indicating 1/4 full, and the right fuel tank gauge was indicating 1/2 full. The nose of the airplane then dropped, and the pilot-rated passenger advised the pilot that the airplane had lost engine power. The pilot-rated passenger then noticed the pilot twisting the vernier-type throttle, and the pilot-rated passenger told him again that the engine was not producing any power.

The pilot then reached down and switched the fuel selector to the left tank. The airplane was not equipped with shoulder harnesses and the pilot-rated passenger noticed that as the pilot leaned forward, his torso pushed against the throw-over control wheel assembly; the airplane pitched sharply downward. The pilot-rated passenger noticed the airplane was approaching trees; he yelled at the pilot who then looked up just as the airplane's left wing struck a tree. After the airplane came to rest, the pilot-rated passenger egressed from the airplane and called 911.

According to automatic dependent surveillance-broadcast (ADS-B) data, the airplane continuously descended on the approach to runway 6 at CPC. The last data point was recorded at 1002, about 2,000 ft from the threshold of Runway 6. PERSONNEL INFORMATIONAccording to FAA airman and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and rotorcraft-helicopter. His most recent FAA third-class medical certificate was issued on February 22, 2016. He had accrued about 3,797 total hours of flight experience, about 2,403 hours of which, were in single engine airplanes.

According to FAA airman records, the pilot-rated passenger, held a private pilot certificate with ratings for airplane single-engine land, and instrument-airplane. His most recent FAA third-class medical certificate was issued on September 19, 2016. He reported on that date, that he had accrued about 1,330 total hours of flight experience. WRECKAGE AND IMPACT INFORMATIONExamination of the accident site revealed that the airplane came to rest in a heavily wooded area near an open field off the approach end of Runway 6 at CPC. The airplane came to rest upright, in a 38° nose down attitude, facing opposite the direction of travel.

Examination of the airplane revealed substantial damage to the outboard left wing.

The throttle was in the full position, the propeller control was in the high rpm (fine pitch) position, the mixture control was in the full rich position, and the fuel boost pump switch was on. The wing flaps were in the 30° extended position and the landing gear was down. The fuel selector valve was in the left tank position.

The left fuel tank contained about 16 gallons of fuel, and the right fuel tank contained about 0.5 gallon of fuel. Both the left fuel tank and right fuel tank quantity transmitters were checked with an ohmmeter; the resistance levels were variable and moved in concert with the floats. When power was applied to the electrical system, the left fuel tank quantity gauge indicated about 1/2 full and the right fuel tank quantity gauge indicated about 3/4 full.

When the left fuel tank quantity transmitters were actuated to full and to empty, the left fuel tank quantity gauge responded accordingly.

When the right fuel tank quantity transmitters were actuated to full, the right fuel tank quantity gauge responded accordingly. When the right fuel tank quantity transmitters were actuated to empty, the right fuel tank quantity gauge still indicated approximately 3/4 full.

The engine did not exhibit physical impact damage. Oil was present in the oil sump, galleries, and rocker boxes. The engine oil dipstick indicated that the oil sump contained about 5.5 quarts of oil. All six upper spark plugs exhibited normal wear patterns, were dry, and exhibited a light color consistent with a lean combustion mixture. Examination of the piston domes, cylinder walls, exhaust valves, and intake valves with a lighted borescope, did not reveal any anomalies. Continuity was established with the cockpit engine controls and the associated engine components. The throttle and mixture control arms remained attached and secured.

Drivetrain continuity was established, thumb compression and suction were achieved on all six cylinders, and rocker arm motion was observed on all valves. Spark was produced by the magnetos to each ignition lead, and the impulse couplers were heard to release. The fuel control inlet screen was clean, and the engine driven fuel pump gear and drive coupling were intact. The fuel pump rotated smoothly, and fuel was expelled when manually rotated. The oil pump appeared normal, and the vacuum pump drive coupling was intact.

Examination of the two-bladed propeller revealed that one propeller blade exhibited S-bending, twisting, and leading-edge paint erosion, with smearing of the red paint that was on the blade tip. The other blade was bent aft around the left side of the engine; the blade was twisted, and the tip was curled aft. Freshly cut sections of tree limbs, about 5 inches in diameter and approximately 15 inches long were observed at the accident site. One section exhibited a red paint transfer mark. ADDITIONAL INFORMATIONFuel System Information

The airplane was equipped with a 74-gallon usable (80-gallon total capacity) optional fuel system that consisted of a rubber fuel cell in each wing leading edge with a flush type filler cap. A visual measuring tab was attached to the filler neck. The bottom of the tab indicated 27 gallons of usable fuel in the wing tank and the detent on the tab indicated 32 gallons of usable fuel in the wing tank provided the wings were level.

Fuel quantity was measured by the float operated transmitters, located in each wing tank system. These would transmit electrical signals to the individual indicators that indicated fuel remaining in the tank. There were two transmitters located in each wing tank system connected to the individual wing tank indicator.

The fuel selector valve handle was located forward and to the left of the pilot's seat. According to the Beechcraft C33 Debonair Pilot's Operating Handbook (POH), takeoffs and landings should be made using the tank that is more nearly full. If the engine stops because of insufficient fuel it stated to refer to the EMERGENCY PROCEDURES Section for the Air Start procedures.

The POH advised that it was the pilot's responsibility to ascertain that the fuel quantity indicators were functioning and maintaining a reasonable degree of accuracy, to be certain of ample fuel for a flight. It cautioned that an inaccurate indicator could give an erroneous indication of fuel quantity.

Published Maintenance Guidance

Review of the airplane manufacturers' published maintenance guidance revealed that instructions for fuel transmitter replacement did exist, and were available to owners, operators, and maintenance personnel. These were contained in the Beechcraft Debonair 33 Series Shop Manual, as well as in the Beechcraft Service Instructions for replacement of fuel transmitters and gauges. The required parts were also listed in the Beechcraft Bonanza C33 Illustrated Parts Catalog.

Review of Airplane Maintenance Records

Review of FAA airworthiness and airplane maintenance records revealed that the pilot purchased the airplane on December 18, 2015. In the years since its manufacture, multiple repairs and replacements of fuel system components had occurred, including installation of a new fuel transmitter in the left wing on October 7, 1983. However, there was no record of the right-wing fuel transmitters having been replaced since the airplane was originally manufactured.

According to the pilot rated passenger, the pilot had been aware of the right fuel tank's fuel quantity indication problem for some time. FLIGHT RECORDERSThe airplane was not equipped with a flight data recorder nor was it required to be. However, the airplane was equipped with a J. P. Instruments EDM-700, a panel mounted engine data monitor (EDM) that can monitor and record up to 24 engine operating parameters. The unit contained recorded data at a sample rate of once every 6 seconds. The data were timestamped based on an internal clock setting that had to...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA18FA012