NTSB Factual Report

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 positioned himself in the cockpit, in an attempt to run the engine. With use of the electric fuel pump, fuel was provided from the left fuel line. The engine started with no difficulties, and remained at an approximate 800 revolutions per minute (rpm) for about 1 minute. The representative shut the engine down and rigged the fuel to flow from the right fuel line; the engine operated at an approximate 1,000 rpm for several minutes with no anomalies. Due to the club propeller used and the compromised engine mounts, investigators did not increase the engine rpm after the engine was started.

The fuel selector was removed and found to be intact. Manipulation of the selector handle revealed there was positive detent in all positions. The fuel transmitters were removed from each wing in an attempt to test the continuity from the sending unit to the cockpit gauges. Investigators were unable to locate the electrical leads running through the cockpit to the left gauge. Both units were connected to the right gauges wires, but the needle on the gauge did not move. The continuity of the right wire was confirmed by use of a multi-meter. The gauge cluster was then removed and the wires to the left gauge were cut. When connected, the left sending unit and left gauge appeared to function normaly with the gauge needle moving in the appropriate direction through the floats normal range of motion. The right fuel gauge, located on the far right of the cluster, had been displaced from the cluster with its wires loose at the post connections. It is not known if this was compromised as a result of impact, as there were impact damaged components surrounding that area. The right sending unit was tested on the left fuel gauge and it appeared to function normally.

There was no evidence of pre-mishap mechanical malfunctions observed during the examination of the engine and airframe, with the exception of the right fuel gauge.

The right fuel quantity gauge was sent to Air-Parts of Lock Haven, Inc., Lock Haven, Pennsylvania, for an examination. The chief inspector who examined the gauge stated that based on the coils, the gauge had the potential to work properly. He indicated that it was not possible to determine calibration, due to its condition. He reported that the green coil showed signs of having been overheated. The coil's normal resistance is 95 ohms; when functionally tested it produced 88.62 ohms of resistance. The red coil's nominal resistance should be 30 ohms; when functionally tested it produced 28.41 ohms of resistance.

NTSB Probable Cause

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.