NTSB Factual Report

HISTORY OF FLIGHT

On May 12, 2011, about 1316 eastern daylight time, a Hawker Beechcraft Corporation G33 Bonanza, N1554W, was substantially damaged during a forced landing to a field near Washington, Pennsylvania. The certificated airline transport pilot/owner was seriously injured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight originated from Washington County Airport (AFJ), Washington, Pennsylvania, around 1315.

According to the pilot, the purpose of the flight was to confirm adjustments made following an initial maintenance test flight he performed the previous day, which followed an annual inspection of the airplane. If the airplane performed satisfactorily, he intended to complete a flight to Rostraver Airport (FWQ), Monongahela, Pennsylvania, and return to AFJ. The pilot stated that he arrived at the maintenance facility, completed a preflight inspection of the airplane, and made "a specific note of the fuel quantity." He also stated that, during the engine run up, he moved the fuel selector to the right tank which was the "fuller of the two" tanks. After the engine ran for approximately 10 minutes, the airplane was taxied for takeoff.

After takeoff, the pilot retracted the landing gear, the engine "choked," and the RPM and manifold pressure decreased. The pilot immediately decreased the pitch attitude of the airplane and made a left turn to the crosswind leg of the traffic pattern while attempting to restart the engine. He stopped the engine-restart attempts as the propeller came to a "standstill" and selected a field approximately one mile from the airport for the forced landing. The airplane landed with the landing gear retracted, and slid to a stop upright, with the wings wrinkled, the engine dislodged from its mounts, and the pilot seriously injured.

According to a mechanic at the maintenance facility, the pilot did not perform a preflight inspection before the accident flight; but immediately entered the airplane, started the engine and then taxied the airplane toward the runway. As the airplane taxied, the mechanic noticed a piece of tape dangling from the airplane that had been placed there during the annual inspection. He signaled the pilot to stop the airplane, removed the tape, and then signaled the pilot to continue the taxi. According to the mechanic and the facility owner/supervisor, 10 to 15 minutes after the airplane taxied from the maintenance facility's hangar, the pilot announced over the radio that "everything concerning the aircraft was running great."

Examination of radar data from the Federal Aviation Administration (FAA) revealed that the target identified as the accident airplane climbed to about 700 feet above ground level before it descended toward the accident site. The total duration of the flight was about 1.5 minutes.

According to the Deputy Director of Public Safety for Washington County Pennsylvania, firefighters, emergency medical technicians, and a HAZMAT team were immediately deployed to the site. The pilot was treated for his injuries, and transported to the hospital. The airplane was then leveled, and secured to the ground with cargo straps.

According to the Director, there was no evidence of fuel spillage at the scene, and therefore no HAZMAT remediation was performed at the site.

WRECKAGE AND IMPACT INFORMATION

The wreckage was examined on May 13, 2011. There was no odor of fuel, and no evidence of fuel spillage at the scene. The initial ground scar was in an open field on a shallow slope, and the wreckage path was 138 feet long and oriented 248 degrees magnetic. The three-bladed propeller was separated from the engine, and found approximately 90 feet beyond the initial ground scar. The main wreckage came to rest upright, and faced about 232 degrees magnetic.

The engine was separated from its mounts, but remained attached to the airplane by miscellaneous cables and lines. The engine rested on its left side, nearly inverted, and was displaced approximately 60 degrees to the right of centerline. The engine was largely intact, but damaged by impact. The starter and pieces of induction system were separated from the engine. The fuel vapor return line, and its 45-degree attachment fitting, were separated from the fuel pump at the housing assembly. Examination of the cowling and the grass beneath the open port revealed no fuel accumulation, no fuel staining, no odor of fuel, and no fuel blight.

The cockpit and cabin area were largely intact. Impact damage and wrinkling of the cockpit floor and exterior sheet metal was evident. The main landing gear was retracted and the main landing gear switch was found in the up position. The left main landing gear door was separated and came to rest about 55 feet prior to the main wreckage. The left front seat lap belt remained attached at both attachment points and the buckle end of the belt was not engaged in the buckle. Testing of the seat belt and the cockpit door revealed that both operated normally.

Control continuity was confirmed from the cockpit to all flight control surfaces, and the flaps were found in the retracted position. The fuel tank selector was found in the left tank position. The auxiliary fuel pump switch was located in the "off" position. The tachometer indicated a time of 1,229.8 hours.

Both wings remained attached to the fuselage at all attachment points. The right wing was bent upwards outboard of the fuel tank. The fuel cap was fully seated and locked. The fuel cap was removed, and the fuel level reached the slot in the filler neck, approximately 2 inches below the cap.

The left wing was bent slightly upwards and the outboard tip leading edge exhibited crush damage. The left wing fuel cap was fully seated and locked. The fuel cap was removed, and examination revealed only a trace amount of fuel in the tank. When the fuel cap was removed, fuel flowed from the open vapor return line port at the fuel pump, and pooled in the damaged cowling beneath it. The engine in its as-found condition placed the fuel pump below both fuel tanks. The fuel selector was moved from the left tank position to the “Off” position, and fuel stopped flowing from the fuel pump. The fuel selector was then moved to the right tank position, and fuel again flowed from the open port in the fuel pump.

Fuel system continuity was confirmed from the left and right wing fuel tanks to the engine.

PERSONNEL INFORMATION

According to FAA records, the pilot held an airline transport pilot certificate with a rating for airplane multiengine land, a commercial pilot certificate with ratings for airplane single-engine land, and instrument airplane. His most recent first class medical certificate was issued on May 20, 2010. The pilot reported 2,790 total hours of flight experience, of which, 800 hours were in the same make and model as the accident airplane. He also indicated that he accumulated 25 hours of flight time in the 90 days prior to the accident.

AIRPLANE INFORMATION

According to FAA records, the airplane was manufactured in 1972. It was a four-seat, low-wing, retractable gear airplane that was equipped with a Teledyne-Continental Motors IO-470-N, 260-horsepower, engine. The most recent annual inspection was completed on May 11, 2011, and at the time of the inspection the airframe accumulated 4,522 total hours. The tachometer indicated 1,228.8 at that time.

According to the Pilot's Operating Handbook (POH), the airplane had a total fuel capacity of 80 gallons; 40 gallons in each tank, of which 3 gallons were unusable. When the fuel tank was serviced to the slot in the filler neck of either tank, that individual tank contained 35 gallons of fuel.

The fuel system was configured so that fuel could be drawn from either tank individually. The fuel tanks could not be drawn from simultaneously, and neither did the fuel system have the ability to cross feed from one tank to the other.

METEOROLOGICAL INFORMATION

The 1355 recorded weather observation at AFJ, located approximately 1 mile northeast of the accident location, included wind from 240 degrees at 5 knots, clear skies, 10 miles of visibility, temperature 25 degrees C, dew point 19 degrees C, and an altimeter setting of 29.96 inches of mercury.

TESTS AND RESEARCH

Engine Examination

The engine was examined at the manufacturing facility in Mobile, Alabama, on June 15, 2011. The crankshaft was rotated by hand, valve train continuity was confirmed, and thumb compression was established on all cylinders. The oil filter and fuel filter were void of any debris. The top spark plugs were removed, all exhibited normal wear, and were light gray in color. The engine was prepared for an engine run and several impact-damaged engine components were repaired or replaced to facilitate engine operation. The engine started on the first attempt and ran without hesitation. The engine throttle was rapidly advanced from idle to full throttle several times where it performed without stumbling or interruption in power. The maximum fuel flow rate during the engine examination was 139.5 pounds (23.5 gallons) of fuel per hour. The engine was run for approximately 25 minutes and then shut down.

Pilot/Owner Fuel Consumption Estimates

The pilot estimated the fuel consumption rate to be 11 to 14 gallons per hour and in a later statement suggested that the maximum consumption rate was 16 gallons per hour. The Pilot's Operating Manual stated that the fuel consumption rate ranged from 6.0 gallons per hour to 22.1 gallons per hour.

Global Positioning System Unit

The NTSB recorders laboratory examined the Garmin 496 Global Positioning System (GPS) unit on May 24, 2011. No pertinent flight log information was downloaded from the GPS as the tracklog memory was “full” and the last recorded flight was in February 20, 2011.

According to the pilot, he had a fuel prompt set on the GPS unit that reminded him to move the fuel selector switch every 15 minutes. Examination of the unit indicated that the fuel reminder mode was set for a 30-minute reminder. Also, the reminder mode was in the "Off" position.

ADDITIONAL INFORMATION

According to maintenance and fueling records, an annual inspection was completed and the airplane was fueled to the "slots" on May 11, 2011; the day prior to the accident. After the fuel service, two test runs of the engine were completed; one by the maintenance supervisor and another by the pilot. The supervisor estimated that he ran the engine for approximately 20 minutes, and taxied the airplane, with no defects noted. Later that day, the pilot arrived at the airport in order to perform a test run of the engine and a test flight of the airplane. Shortly after the pilot's arrival, the mechanic heard the "engine cranking for a long duration without starting." He then asked his supervisor to assist the pilot with starting the engine.

According to the supervisor, he boarded the airplane and asked the pilot to verify the fuel selector was in an "on" position. The pilot remarked "oh," and the supervisor heard the pilot move the fuel selector one position. After that, they primed the engine, and the airplane started. Prior to the flight, the supervisor requested that the pilot perform an aborted takeoff before beginning the test flight, and cautioned the pilot/owner to "stay in the [traffic] pattern" during the test flight.

About 20 minutes after the airplane taxied from the facility, the supervisor noted that the accident airplane could not be heard in the pattern, and the pilot failed to respond to calls from his hand-held radio. The supervisor then searched the airport in his personal vehicle for the airplane, and proceeded to the main terminal when his search was unsuccessful. Airport personnel were able to contact the pilot on the UNICOM frequency, and the pilot reported that his position was "20 miles south" of the airport.

Examination of radar data from the day of the test flight revealed that the radar target identified as the airplane climbed to 10,200 feet, and was aloft for approximately 30 minutes.

According to a placard affixed to the tachometer, "Hourmeter recording rate is correct at 2310 RPM."

According to the Pilot's Operating Manual, the ninth item on the "Before Starting" checklist states "Fuel Selector – ON, Fuller tank."

The Limitations section of the POH, and a placard by the fuel selector both stated, "Do not take off if fuel quantity gages indicate in yellow band or with less than 13 gallons in each main tank."

The "Engine Failure on Take-off" emergency procedure stated that if insufficient runway remained for landing to:

1. Fuel Selector – Fuller Tank

2. Boost Pump – On

3. Mixture – Full Rich

4. Magnetos – Check, On Both

IF NO RESTART

1. Select most favorable landing site ahead.

2. Gear down before landing.

Then, the manual stated "the most probable cause of engine failure would be loss of fuel flow or improper functioning of the ignition system."

NTSB Probable Cause

A total loss of engine power due to fuel starvation, as a result of the pilot's improper fuel management and preflight inspection. Contributing to the accident was the pilot's failure to comply with the manufacturer's published takeoff and emergency procedures.