NTSB Factual Report

HISTORY OF THE FLIGHT

On June 6, 1994, at 1540 eastern daylight time, a Beech B24R, N9258S, owned and operated by Vest Air Leasing Inc. of Haverhill, Massachusetts, was destroyed when it impacted the ocean about 12 miles north of Nantucket, Massachusetts during a power-off forced landing. The certificated commercial pilot was fatally injured, the one passenger was not recovered and presumed dead. Visual meteorological conditions (VMC) prevailed and no flight plan was filed for the flight, which was conducted under 14 CFR Part 91. The flight departed Lawrence, Massachusetts, at 1440.

The pilot had completed a Biennial Flight Review (BFR) in the accident airplane, which was based at Lawrence Municipal Airport (LWM), in Lawrence, Massachusetts, on June 2, 1994. The flight instructor who administered the BFR stated the airplane was fueled to the tabs prior to the BFR. The airplane was flown 1.5 hours during the BFR flight. After the BFR was accomplished, the pilot and two passengers flew the accident airplane to Nantucket Memorial Airport (ACK), Nantucket, Massachusetts. There were no fuel receipts to show the airplane was refueled prior to this flight. After landing at ACK, the pilot requested the Airport Fixed Base Operator (FBO) to "fuel the plane to the tabs". Two fuel receipts, dated June 2 (19.6 gallons) and June 5 (9.5 gallons), respectively, are appended. There is no evidence that the airplane received fuel at any other time in the four days preceding the accident.

According to a family spokesperson, the pilot departed ACK at 1700 on June 5, and transported two passengers to the airport at Lawrence, Massachusetts. The pilot remained overnight in Lawrence. On June 6, the pilot and one passenger (the pilot's son) departed LWM about 1440 for the return flight to ACK.

According to Federal Aviation Administration (FAA) records, the pilot was receiving VFR Advisory Service when he reported his engine lost power. He stated that he was unable to maintain altitude and was ditching the airplane. Radar and radio communications with the accident airplane were lost at 1540. FAA Air Traffic Control (ATC) records indicate that the airplane's last observed altitude was 600 feet, at a position approximately 12 nautical miles north of the Nantucket Memorial Airport.

ATC personnel vectored two aircraft that were flying in the vicinity to the point of last radar contact. Both aircraft flew over the accident area within minutes of the ditching; neither pilot observed any airplane debris or survivors in the water. The pilot's body was recovered from the water 10 days after the airplane was ditched by a local fisherman; the one passenger was not found and presumed dead.

PILOT INFORMATION

The pilot held a Commercial Pilot Certificate issued March 22, 1986, with an instrument rating for airplane single engine and multiengine land. His second class medical was dated April 12, 1994.

Examination of the pilot's flight logbook indicated his total flight time was approximately 2389 hours. Since August, 1987, the pilot had flown approximately 607 hours, with numerous trips between LWN and ACK. Of the 607 hours, 593 were flown prior to October, 1992, in either a Beech King Air or a Piper Cheyenne. Logbook records indicated that the pilot had 3 hours total flight time in the accident make and model airplane prior to the extended trip during which the accident occurred. These 3 hours were dual instructional flights. The pilot had not logged his flights after the BFR (from LWN to ACK on June 2, and the return flight from ACK to LWN on June 5). This extended trip was the first time the pilot had utilized the accident airplane without the supervision of a flight instructor. According to acquaintances, the pilot was flying the accident airplane with the intention of purchasing it and utilizing it for trips such as this, since he owned a house on Nantucket.

The flight instructor who administered the BFR stated the pilot "did a great job flying and was meticulous with the checklists." The flight instructor stated he had specifically made a sheet which showed how much useable fuel was onboard when the airplane was filled to the tabs, slots, and full. This sheet also depicted how much weight could be carried with these respective fuel loads. The instructor reported he had shown the pilot how to lean the fuel during cruise by setting 23 inches MP, 2400 RPM, and leaning the fuel to 1375-1400 degrees on the digital EGT. The flight instructor stated that after the above procedures were completed, the fuel flow meter would indicate "about 9 gallons per hour, but in fact was burning more likely, 10-10.5 gallons per hour."

AIRCRAFT INFORMATION

The accident airplane, a 1976 Beech B24R, was equipped with a single Lycoming IO-360-A1B6 (200 horsepower) engine. The aircraft maintenance records showed the most recent annual maintenance inspection was accomplished on June 1, 1994, at an engine tachometer time of 3357.79 hours. Records indicated that at that time of the annual inspection, the engine had operated 70.29 hours since major overhaul (SMOH).

The Pilot Operating Handbook (POH) for the accident airplane indicated that the airplane is capable of carrying 58 gallons of fuel (29 gallons each tank), of which 52 gallons is considered useable. In the filler neck of each tank is a visual measuring tab which permits partial filling of the fuel system. When the fuel touches the bottom of the tab it indicates 15 gallons of fuel in each tank with 22.4 total useable gallons. When filled to the slot in the tab it indicates 20 gallons of fuel in each tank with 32.4 total useable gallons. The POH also states that the indicating system (fuel gauges) reads full at 20 gallons. The pilot must visually check the fuel level during preflight to ascertain desired level. Adjacent to the engine instrument cluster, there is a placard which states, "DO NOT TAKE OFF WHEN FUEL QUANTITY GAUGE INDICATES IN YELLOW OR WITH LESS THAN 11 GALLONS IN EACH MAIN TANK."

Information received from the airplane manufacturer indicated that the power setting to which the flight instructor taught the pilot to lean to corresponds with a cruise power setting of 65% maximum continuous power. The manufacturer's information indicated that, on a standard day at that power setting, a pilot could expect a fuel flow of 9.1 GPH.

METEOROLOGICAL CONDITIONS

The ACK weather observation taken at 1545 estimated the ceiling at 5000 feet broken, 15000 feet overcast, with visibility of 10 miles. The temperature was 63 degrees, dewpoint 57 degrees, the winds were from 240 degrees at 10 knots, altimeter 30.00" Hg. At 2000, the observed winds aloft taken from Chatham, Massachusetts, showed winds from approximately 230 degrees at 35 knots between 1000 and 3000 feet. It is unknown if the pilot obtained weather information prior to his departure.

WRECKAGE AND IMPACT INFORMATION

The aircraft was located several days after the accident using Sonar equipment. The LORAN latitude/longitude coordinates for the aircraft wreckage were 041 degrees, 27 minutes, 96 seconds North, and 070 degrees, 10 minutes, 88 seconds West. The aircraft was intact. An attempt to salvage the aircraft on June 23 was unsuccessful as the barge capsized after the aircraft was raised out of the water. The aircraft was recovered on July 8 and transported to LWM for examination.

Both cabin doors were found in the open position, and both front seat belts were found unbuckled. The instrument panel and cockpit controls exhibited no impact damage. The throttle control lever was in the full aft position. The mixture and propeller controls were found in the full forward positions. The landing gear and flap switches were found in the UP position. The flap position indicator exhibited an UP indication. The magneto switch was found in the left position with the key missing. The battery, alternator, and boost pump switches were in the ON positions. The fuel selector valve was in the OFF position. None of the circuit breakers were popped.

Both wings exhibited a slight upward distortion. The inboard portion of both fuel tank leading edges exhibited buckling. There was a small tear and a hole in the leading edge of each fuel tank. Sea water had filled both fuel tanks, and the water was observed leaking out of these holes. The main fuel strainer drain valve and both fuel tank drain valves were in the closed position. Both fuel tanks were cut open for inspection and exhibited minor marine plant growth. The outside of both fuel tank strainers exhibited partial blockage from the marine growth.

The throttle, mixture, and propeller control positions at the engine coincided with the cockpit control positions as described above. The throttle, mixture, and propeller control linkages exhibited continuity from the cockpit control levers to their respective engine control levers.

The fuel selector valve and handle, the main fuel strainer/bowl, the boost pump, the engine driven fuel pump, the fuel injector servo, the fuel injector servo strainer and all of the connecting fuel lines were found intact, unobstructed and properly assembled.

The engine crankshaft rotated freely and all four cylinders exhibited thumb compression. Valve train continuity was established. The engine-driven fuel pump and both magnetos were corroded and their casings were compromised. When the propeller was rotated, the engine-driven fuel pump arm exhibited movement.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's body was recovered 10 days after the accident. An autopsy was conducted by William Zane, M.D., at The Commonwealth of Massachusetts, Office of Chief Medical Examiner, Southeastern Regional Office, 870 County Road, Pocasset, Massachusetts, 02559, (508) 564-6371. The autopsy attributed the pilot's cause of death to asphyxia due to drowning. Toxicological examination of the pilot did not reveal evidence of preimpact anomaly. The one passenger was not recovered and is presumed dead.

SURVIVAL ASPECTS

Post accident inspection showed minimal damage to the exterior/interior of airplane. Although the owner/operator had personal floatation devices/survival equipment available, there was no such equipment on board the airplane at the time of the accident. The owner had removed the devices from the airplane and placed them in his hangar since he had recently bought a new airplane.

At the time of the accident the reported water temperature was mid 50 degrees, and the outside air temperature was 63 degrees. Additionally, swift currents were reported. According to the WATER TEMPERATURE PROTECTION CHART, page 4-15, Chapter 4, U.S. Navy Diving Manual, Vol. 1, titled "Air Diving" published by the Naval Systems Command, the expected survival time with the above conditions would be one to two hours. The chart is appended.

ADDITIONAL INFORMATION

The airplane wreckage was released to the owner's representative on September 14, 1994.

NTSB Probable Cause

the total loss of engine power over unsuitable terrain, for undetermined reasons. The pilot's failure to ensure that proper survival equipment was onboard the airplane was a related factor.