NTSB Factual Report

HISTORY OF FLIGHT

On June 28, 1997, at 1139 eastern daylight time, a Beech BE-35-C33A, N4863J collided with trees while attempting an instrument approach to runway 24 at Woodward Field in Camden, South Carolina. The personal flight operated under the provisions of Title 14 CFR Part 91 with an instrument flight rules (IFR) flight plan filed. Instrument weather conditions prevailed at the time of the accident. The airplane sustained substantial damage. The commercial pilot and one passenger received serious injuries, and one passenger was fatally injured. The flight departed from Riverview Airport in Jenison, Michigan at 0730 eastern daylight time.

Before departure, the pilot received a full weather briefing from the Lansing Flight Service Station, Lansing, Michigan. The briefing indicated that there was high pressure over most of the route until the South Carolina area where there was a cold front. There were rain showers in Camden, with a convective SIGMET slightly south of the Camden area. After the briefing, he filed an IFR flight plan.

The airplane approached Woodward Field from the northwest and was transferred to Shaw Air Force Base Approach Control. The approach controllers then cleared the pilot to make a Non-Directional Beacon (NDB) 24 approach into Camden. After flying outbound on the published procedure turn, the airplane turned inbound and was unable to re-intercept the inbound course. When the airplane was approximately 4 miles north of the airport, the approach controllers cleared the pilot to fly direct to the NDB in order to attempt a second approach. After the pilot repeated the clearance and made a turn, the airplane did not appear to the controllers to be correctly lined up for the NDB. The controllers then attempted to give the pilot vectors to the NDB course, believing his gyro to be inoperative. While vectoring him, the pilot began to descend below the minimum safe altitude of 2000 feet. After repeated warnings from the approach controllers to climb, communication and radar contact were lost with the airplane about 8 1/2 miles southwest of the airport.

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with single engine land, multi-engine land, and instrument airplane ratings. He was also a private pilot with a helicopter rating. His certificate was issued September 11, 1993. His last medical certificate, a second class, was dated April 1, 1997, and contained the limitation that the pilot must wear corrective lenses in order to exercise the privileges of the airman's certificate. The pilot had a biennial flight review on August 6, 1996. He completed an instrument competency check on March 24, 1997.

Additional information about the pilot is contained on page 3 under the title First Pilot Information.

AIRCRAFT INFORMATION

The airplane and engine records were inspected, and showed no discrepancies. All Airworthiness Directives had been complied with, according to the aircraft's records. The last inspection of the aircraft, an annual, was July 22, 1996. It was completed in Holland, Michigan. The engine had an annual inspection on December 16, 1996, also in Michigan.

Additional information about the aircraft is contained on page 2 under the section titled Aircraft Information and in the report from Teledyne Continental Motors.

METEOROLOGICAL INFORMATION

The conditions at the time of the accident were instrument meteorological conditions. At the time of the approach, there was no precipitation, but according to the METAR report, the rain had ended about 13 minutes prior to the accident. The ceiling was 800 feet broken.

Additional information about the weather is contained on pages 3 and 4 under the section titled Weather Information.

WRECKAGE AND IMPACT INFORMATION

When investigators arrived at the scene, the airplane was nosed over with the empennage resting on a tree. All parts of the airplane were together, with the exception of a navigation light lens, which was located approximately 66 1/2 feet away from the main wreckage. The wreckage was distributed along a 010 degree azimuth line. The airplane was in a wooded area with sparse underbrush. The airplane had leaves and branches laying on the right side of the wreckage.

A tree, in the area where the navigation light lens was found, showed significant damage. It had a fresh break at a height of 25 feet. The tree was about 3 feet in circumference.

The right wing leading edge had a circular indentation about 5 feet from the root. Inside the indentation, there was leaves, twigs, and bark. The wing also had bulges from hydraulic expansion. Approximately three gallons of fuel were found in the right fuel tank, which was breached at the point of the indentation. The trailing edge flap was in the "up" position, and the aileron exhibited mechanical continuity.

The empennage was connected to the fuselage. All tail surfaces exhibited mechanical continuity. The only visible damage was two circular indentations on the right horizontal stabilizer. The first one was about 3/4 of the way to the horizontal stabilizer tip. The second indentation was at the junction of the fuselage and the right horizontal stabilizer.

The left wing exhibited crumpling damage along the leading edge. There was one circular indentation in the left wing about 2/3 of the way from the root. The fuel tank exhibited structural integrity, and contained approximately three gallons of fuel. The aileron exhibited mechanical continuity, and the trailing edge wing flap was in the "up" position.

The fuselage exhibited wrinkles that were perpendicular to the longitudinal axis of the airplane. The right side had a large circular indentation directly over the registration number. The right door was separated from its mounts. Examination of the airplane's landing gear system revealed the landing gear was extended.

The engine and propeller assembly were deflected 90 degrees to the left from their normally installed position, so they pointed at the left wing. The engine cowling contained fresh leaves and twigs. The propeller, a three blade version, showed damage on all three blades. The first propeller blade was twisted and bent in a wide arc to the rear. The other two blades were slightly twisted at the tips.

The fuel tank selector in the cockpit had the left tank selected. All other instrument indications can be found in Supplement B.

According to the rescue personnel, the pilot had both contacts and glasses in the airplane.

Subsequent investigation of the engine, an IO-520-BA, Serial Number 232649-R, showed the engine exhibited mechanical continuity. The engine was able to be rotated by hand. The magneto impulse coupling was heard popping as the engine was rotated. A compression check showed the engine was able to sustain compression as measured by placing a thumb over the spark plug hole. Both of the Slick magnetos were able to produce a spark. The fuel pump was able to be rotated by hand, and the fuel pump coupling was intact. The spark plugs, Champion RHB32E, exhibited normal wear as compared to the manufacturer's wear indication chart. Spark plugs 1,3, and 5 showed a whitish deposit. The fuel/air mixture control unit had a clean screen.

The engine was successfully run on a test cell after changing the ignition harness, epoxying a hole in the induction pipe, changing the oil sump, and replacing the fuel metering unit. The fuel metering unit was later examined and found to produce a good flow, slightly high pressure, and very little fuel bypass. The ignition harness had damage to some of the leads. At high speeds, the top #1, top #5, and bottom #3 leads did not spark. There were visible cuts in all of these leads. At a low speed, only the bottom #2 lead produced a spark.

The radios were also removed from the wreckage and tested to determine if they were operating properly. It was discovered that both communication radios, the LORAN navigation system, both VORs, both ILSs, and the DME were all performing within operating specifications. No abnormal readings were found at any of the numerous frequencies tested. The ADF receiver was unable to be tested due to impact damage.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot received multiple traumatic injuries. No toxicological tests were performed on him.

ADDITIONAL INFORMATION

The airplane was refueled with 31.41 gallons of fuel the day before the accident at Riverview Airport, Jenison, Michigan.

According to both the engine and airframe manufacturers, the airplane's tanks held 74 gallons of usable fuel, 6 gallons of unusable fuel, and would have burned 17gallons per hour (gph) in the start, taxi, run-up, maneuvering, and climb phases, and 15 gph in the cruise and descent phases. These numbers are based on the pilot's statement that he was cruising at 75% power, on a standard day, about 156 kts, and at a cruise altitude of 10,000 feet. The total trip distance was approximately 590 nautical miles.

The pilot stated he began with full tanks or 74 gallons of fuel. The pilot stated he took approximately 15 minutes to complete the start, taxi, and run-up. The airplane then climbed to 10,000 feet. As he began his cruise, the pilot should have had 64.65 gallons of fuel left to burn. After cruising for 455 miles, the airplane was left the airplane with approximately 20.9 gallons. At this point, the airplane was at 10,000 feet and beginning its descent. The descent lasted approximately 100 miles, according to the pilot. Upon arriving at the bottom of descent, 2000 feet, the airplane was left with 11.1 gallons of fuel. The pilot then maneuvered the airplane at 2,000 feet for 10 minutes while attempting the approach into Woodward Field. At this point, the airplane should have had 8.2 gallons of fuel left in the fuel tanks. Using the manufacturer's numbers, this would have allowed the pilot to maneuver for an additional 29 minutes at 2,000 feet.

The Federal Aviation Administration requires that an airplane carry enough fuel to arrive at a destination with a reserve quantity of fuel. In the case where the prevailing weather is instrument meteorological conditions, the airplane must "complete the flight to the first airport of intended landing, fly from the airport to the alternate airport, and fly after that for 45 minutes at normal cruising speed".

According to the pilot, when his engine quit, he put his boost pump on, put the mixture to rich, and set the throttle to 1/4 of the way in. The engine was windmilling, but did not restart. After waiting for a restart, he then decided to bring the mixture to lean as to not flood the engine. After a few unsuccessful attempts, he began turning equipment off, considering his close proximity to the ground.

The engine restart checklist calls for the pilot to also switch fuel tanks. When asked why he did not switch tanks, the pilot stated he looked at the fuel gage and noted which was the fuller tank. According to the gages, the left tank was fuller, so he did not switch to his right tank.

The approach minimum for the NDB 24 into Woodward Field was 940 feet mean sea level (msl). After the accident, the NDB 24 approach into Woodward Field was taken out of service to be tested. On July 10, 1997, the NDB 24 was flight checked with no anomalies found. It was returned to service that same day.

NTSB Probable Cause

improper fuel management by the pilot by not positioning the fuel selector to the fullest tank for landing, which resulted in fuel starvation, loss of engine power, and a forced landing. Trees in the emergency landing area were a factor.