NTSB Factual Report

HISTORY OF FLIGHT

On December 18, 2013, about 0720 central standard time (CST), a Raytheon Aircraft Company model G36, N89SN, impacted trees and terrain during a forced landing attempt near Panama City, Florida. The airline transport pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to and operated by Grey Aviation, Inc. as a business flight. Day, visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight originated from North Palm Beach County General Aviation Airport (F45), West Palm Beach, Florida about 0554 eastern standard time (0454 CST) and was destined for Destin-Fort Walton Beach, Florida (DTS).

The flight was about 60 miles from the destination airport when the pilot reported to Tyndall air traffic control (ATC) that he had lost all engine power. The controller provided information on nearby airports and the pilot maneuvered the airplane in the direction of Sandy Creek Airpark (75FL), a fly-in community. The pilot reported the airport in sight and radio and radar contact was eventually lost. A search for the airplane was initiated, and the wreckage was located in a heavily wooded swamp about one mile east of 75FL. There were no known witnesses to the accident.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with ratings for airplane single engine land and airplane multi-engine land. He reported a total flight experience of 5,000 hours, including 50 hours during the last six months, on his class 1 medical certificate application, dated March 20, 2013. The medical certificate included a restriction to wear corrective lenses for near and distant vision.

According to the airplane's owner, the accident pilot was the sole pilot of the airplane since its purchase. The airplane was purchased by its present owner on August 28, 2013. Since then, according to an aircraft flight logbook, about 53.5 hours of flying time had accumulated at the time of the accident.

AIRCRAFT INFORMATION

The airplane was a Raytheon Aircraft Company model G36 that was manufactured in 2006. It was powered by a Continental IO-550B engine, rated at 300 horsepower at 2,700 rpm and was equipped with a Hartzell three-bladed constant speed propeller.

The Hobbs time recorded at the accident site was 734.2 hours. The last annual inspection on the airframe and engine occurred on August 22, 2013 at an airframe total time of 683.0 hours Hobbs time. The last recorded maintenance included Garmin G1000 upgrades on October 3, 2013 at Hobbs time 722.8 hours.

No recorded flight and engine data was obtained from the G1000 system as the Secure Digital (SD) card required to record such data was not installed.

METEOROLOGICAL INFORMATION

The 0658 CST surface weather observation for Tyndall Air Force Base (PAM), located about 5 miles southwest of the accident site, included sky clear, wind from 020 degrees at 9 knots, visibility 10 statute miles or greater, and altimeter setting 30.32 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The wreckage was found generally intact and upright, on a heading of 270 degrees magnetic, at coordinates 30.101966, -85.462343. There was no evidence of fire noted. The local terrain consisted of flat, heavily-wooded, sandy soil, saturated with water. The airplane struck two 8-10 inch diameter pine trees; one at the right wing root and one about 1/4 wing span distance outboard on the left wing. There was a ground scar under the forward fuselage area about 5 feet long by two feet wide by six inches deep. The ground scar was filled in with water.

The fuselage exhibited light buckling just aft of the engine firewall. Each horizontal stabilizer leading edge had multiple dents from tree and/or bush strikes. A pine tree, about 10 inches in diameter, was found uprooted. The lower half of the tree was found under the left wing and the upper half was found resting on top of the airplane's rear fuselage. The tree strike at the right wing root pushed the leading edge upward and restricted the cabin door from being opened.

The Garmin G1000 Multi-Function Display (MFD) glass panel was shattered and showed evidence of impact by the pilot.

All primary flight control surfaces remained attached, and flight control continuity was confirmed from the cockpit controls to all surfaces. The aileron trim tab was found in the neutral position, and elevator pitch trim was found slightly nose up and within the green band. The landing gear and wing flaps were found in the retracted (up) positions.

The throttle was found aft, near the "idle" position, the propeller lever was aft at the "full decrease" position, and the mixture lever was full forward at the "full rich" position. The auxiliary/emergency fuel boost pump switch was in the "OFF" position. Engine control linkage continuity was established from the cockpit controls to their respective engine connections.

The three-blade, constant speed propeller remained attached to the propeller flange and all three blades remained within the propeller hub. One blade displayed minor aft bending deformation, another blade displayed significant aft bending deformation, and the third blade appeared to be undamaged. None of the blades displayed rotational damage or signatures. The propeller blade with minor bending could be freely moved within the hub; the other two blades were secured inside the hub.

The engine remained attached to the airframe and there was no discernable impact damage to the engine. No oil leaks were observed. All of the cylinders remained attached to their respective installation points and there were no anomalies noted with the cylinders. The crankcase was intact and there were no anomalies noted. After the engine driven fuel pump was removed, the crankshaft was rotated approximately one quarter turn and it was noted that the crankshaft was continuous from the front to the rear of the engine.

The left and right magnetos remained attached to their respective installation points and appeared to be undamaged. The ignition harness remained attached to the magnetos and to the spark plugs and there were no signs of damage or abnormalities to the ignition harness. The top spark plugs were removed and visually inspected. All of the top spark plugs displayed normal operating signatures when compared to Champion Aviation Service Manual AV6-R.

The engine-driven fuel pump remained secured to its installation point and appeared to be undamaged. The fuel lines were removed from the fuel pump; only residual fuel remained in the fuel pump outlet line, and there was no fuel observed in any of the other lines. The fuel pump was removed and the drive coupling was noted to be intact. The fuel pump was rotated by hand and the pump rotated freely; it was noted that no fuel pumped out of the fuel pump during rotation. The fuel inlet line leading to the fuel manifold valve was disconnected from the fuel flow transducer by the investigation team and only residual fuel was noted in the fuel line. There were no signs of fuel leaks or external abnormalities with the fuel manifold valve or the fuel nozzles. The fuel metering unit and the throttle body were only partially visible to the investigation team; there were no abnormalities noted with the visible portions of the throttle body and fuel metering assembly.

The fuel tank selector handle was found in the "left main" wing tank position. Investigators tested the fuel selector's functionality by blowing forced air into the fuel selector though the fuel line removed from the engine-driven fuel pump. The selector valve functioned normally in the left and right main tank positions, and no obstructions in the fuel lines to the main tanks were observed.

A 40-gallon bladder tank, of which 37 gallons were useable, was housed in each wing, positioned from the wing root to about one third wing span outboard. Less than 1 pint of fuel was recovered from the left tank. No evidence of fuel leakage was observed on the ground under the tank. The fuel lines leading from the left tank to the airframe were connected and unbroken. The fuel probe and baffle flapper appeared normal. The fuel tank finger screen was clean and free of obstructions.

The right main tank was breached on the inboard, forward end due to impact damage to the wing's leading edge. A residual amount of fuel drained from the bladder when the wing was removed by recovery personnel. The soil directly under the right wing showed no evidence of fuel spillage; no odor or visible layer of fuel was observed. The fuel probe and baffle flapper appeared normal. The fuel tank finger screen was clean and free of obstructions.

The airplane was fitted with 20-gallon wing tip tanks. Each wing tip tank was designed to feed fuel to its main tank when its boost pump, mounted in the wheel well, was activated. Each wing tip tank was empty when visually checked. No evidence of spilled fuel was found directly under or near the tip tanks. The two boost pump switches, mounted on the left side of the instrument panel, were found in the "off" positions.

When the fuselage was lifted by aircraft recovery personnel, a ground scar was present. The ground scar was filled in with water due to the saturation of the soil at the accident site. A layer of fuel was observed on top of the surface of the water, which was collected and quantified by investigators. The total amount of recovered fuel, including the residual fuel in the tanks, was about 2.5 gallons. Once the wreckage was removed from the accident site, investigators examined the vegetation in and around the main wreckage; no discoloration consistent with fuel spray or leakage was observed.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed at the offices of the District 14 Medical Examiner, Panama City, Florida, on December 20, 2013. The autopsy report noted the cause of death as "Blunt Force Head Trauma" and the manner of death was "Accident."

Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated no carbon monoxide in the blood, and no ethanol was detected in the vitreous. Cyanide testing was not performed. Dextromethorphan was detected in the blood but not in the urine. Dextromethorphan (Robitussin®, Delsym®, Sucrets®, Bromfed-DM®, Tylenol Cold®, NyQuil®) is an over-the-counter cough suppressant also found in prescription cough medications. It is metabolized into dextrorphan, which also has cough suppressant properties. Ibuprophen was detected in the urine. This medication is an over-the-counter Non-Steroidal Anti-Inflammatory Drug (NSAID). It is used as an anti-inflammatory medication to treat aches and pains, as an antipyretic to reduce fever.

SURVIVAL ASPECTS

First responders noted that the pilot's lap belt remained attached and he was seated in the left cockpit seat; however, he was slumped forward and to his right. The pilot's shoulder harness was not attached and was undamaged.

TESTS AND RESEARCH

Engine Examination and Test Run

The engine was examined at the Continental Motors facility at Mobile, Alabama on April 8 and 9, 2014. Due to minimal impact damage, a test run was attempted and the engine was not disassembled. Prior to the test run, the engine oil cooler was removed and replaced due to impact damage. Dried mud was removed from the intake system. The engine contained about 11 quarts of oil. The spark plugs were cleaned of rust due to prolonged storage prior to the test run. The plugs operated normally on a test bench.

After installation in a test cell, the engine started on the first attempt. The engine ran smoothly and without hesitation at an array of throttle settings from idle through full throttle (2,648 RPM observed). All engine parameters were observed to be in the normal operating range. Magneto checks were normal.

Fueling History

According to a flight logbook recovered from the wreckage, the airplane was parked at Tampa International Airport (TPA), Tampa, Florida from November 17-22, 2013. On November 22, 18.2 gallons of 100 octane low lead (100LL) aviation gasoline were purchased at a fixed base operator (FBO) at TPA. This was the last known record of a fuel purchase for N89SN prior to the accident. The airplane arrived at F45 on November 22 following a direct flight from TPA and remained there until the initiation of the accident flight on December 18. According to personnel at F45, no fuel was purchased for the accident airplane between November 22 and December 18.

According to the flight logbook and the Hobbs meter on the airplane, the airplane departed TPA at 729.9 Hobbs time. The Hobbs time recorded at the accident site was 734.2 hours (4.3 hours elapsed since last fueling). Although the amount of fuel purchased on November 22 was known, the amount of fuel on board the airplane after the last refueling could not be determined.

ATC Transcript of Communications

According to a transcript of communications provided by Tyndall ATC, the pilot, at 0715:36, stated, "We're losing uh oil here for some reason." A copy of the audio transmission was also provided to investigators. The audio file was then forwarded to the NTSB Vehicle Recorders lab for examination. Their assessment was that the term "oil" referred to by ATC was deemed unintelligible.

NTSB Probable Cause

The pilot’s inadequate preflight and inflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion. Contributing to the pilot’s injuries was his failure to use the available shoulder harness.