Monday, April 22, 2019

Loss of Control in Flight: Beechcraft 58 Baron, N501CE; fatal accident occurred April 22, 2019 near Kerrville Municipal Airport (KERV), Kerr County, Texas

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas
Continental Aerospace Technologies; Mobile, Alabama
Textron Aviation Inc; Wichita, Kansas

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


https://registry.faa.gov/N501CE

Location: Kerrville, TX
Accident Number: CEN19FA124
Date & Time: 04/22/2019, 0851 CDT
Registration: N501CE
Aircraft: Beech 58
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 6 Fatal
Flight Conducted Under: Part 91: General Aviation - Business

Analysis 

The pilot was conducting an instrument flight rules (IFR) flight in a twin-engine airplane with five passengers. During a GPS approach to the destination airport, both engines lost total power within 10 seconds of each other; the left engine regained near full power about 40 seconds later, which it maintained until the end of recorded data. As the pilot continued the approach, he did not ensure the flaps were up or feather the propeller of the inoperative right engine, which was contrary to the airplane manufacturer's emergency procedures guidance.

As the airplane descended with the right engine inoperative below the cloud ceiling to about 500 ft agl, its flightpath leveled and airspeed decreased below the minimum controllable airspeed (Vmc). The airplane's continued flight profile below Vmc with the unfeathered propeller of the inoperative right engine, the left engine near full power, and the airplane's aft center of gravity resulted in a right-turning spin and ground impact.

The pilot's filed flight plan indicated a minimum fuel load required of 58 gallons, although this did not account for the instrument approach and alternate airports. However, the pilot's flight planning log indicated only 50 or 54 gallons of fuel onboard. Thus, based solely on the pilot's logs, there was insufficient fuel onboard the airplane to embark on the flight. Because the airplane was beyond its maximum gross weight with just 50 gallons of fuel onboard, it is likely that the pilot did not want to add additional fuel. Thus, the pilot's decision to depart on the accident flight without adequate fuel onboard showed poor judgement.

Although the pilot departed without an adequate fuel reserve for the IFR flight, an actual fuel load of 50 or 54 gallons would have been sufficient to reach the destination airport (the airplane burned about 42 gallons just before the crash site about 6 miles from the airport). However, when the airplane was fueled at the pilot's request 8 days (five flights) before the accident flight, it was not completely filled. Because the pilot was not present for the fueling and did not crosscheck the fuel receipt with his fuel-planning logs, he did not recognize that the error meant he had less than 50 gallons of fuel onboard before departing on the accident flight. As evidenced by the close correlation between the pilot's fuel logs and the engine data monitoring (EDM) fuel consumption data for the accident flight and the five flights before it, the pilot mainly relied on EDM data to determine the quantity of fuel onboard the airplane. Thus, the fueling error introduced 8 days before the accident was carried through the pilot's planning logs for the next six flights, including the accident flight.

Further review of the accident airplane fueling records, the pilot's flight-planning logs, and fuel consumption data from the EDM revealed that the airplane actually had about 12 gallons less fuel than the pilot indicated in his fuel log for the accident flight. Thus, the lack of sufficient fuel for the accident flight resulted in the airplane's engine power loss during the approach.

In addition, the abnormally high resistances in both fuel quantity transmitters would have caused the cockpit fuel quantity indicators for both wings to read about 5 gallons higher each than the actual fuel present, corresponding to an additional 1/16th tank on each of the indicators. Thus, because of the high resistances in both fuel quantity transmitters, the pilot's belief that 50 (or 54) gallons of fuel were onboard at takeoff (rather than the actual fuel level of 38 gallons) may have been corroborated by the fuel quantity indicators; however, the effect of the inaccurate indications on the pilot's actions are uncertain.

The pilot's autopsy indicated he had severe coronary artery disease, which placed him at increased risk of a sudden cardiac event. However, the accident sequence was not consistent with acute pilot impairment or incapacitation as recorded data indicate that the pilot was controlling the airplane up until the airplane dropped below its minimum controllable airspeed, so it is unlikely that the pilot's coronary artery disease or any sudden medical event contributed to this accident.

In summary, multiple errors before takeoff led to a loss of engine power due to fuel exhaustion. The pilot did not accurately record the amount of fuel added after fueling, the pilot did not verify the amount of fuel onboard the airplane, the fuel quantity transmitters did not accurately indicate the amount of fuel onboard, and the pilot decided to take off with inadequate fuel to conduct the IFR flight in an overweight airplane. Lastly, during the flight, once the right engine lost power, the pilot failed to properly configure the airplane per the manufacturer's emergency procedures guidance and allowed the airspeed to drop below the point at which the airplane could maintain flight. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's inadequate preflight fuel planning and fuel management, which resulted in a loss of engine power due to fuel exhaustion. Also causal was the pilot's failure to follow the one-engine inoperative checklist and maintain the airplane's minimum controllable airspeed by properly configuring the airplane, which resulted in a loss of airplane controllability. 

Findings

Aircraft
Fuel - Fluid management (Cause)
Fuel - Fluid level (Cause)
Airspeed - Not attained/maintained (Cause)
Performance/control parameters - Not attained/maintained (Cause)
Fuel quantity indicator - Damaged/degraded
Maximum weight - Capability exceeded

Personnel issues
Fuel planning - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Use of checklist - Pilot (Cause)
Aircraft control - Pilot (Cause)
Flight planning/navigation - Pilot
Weight/balance calculations - Pilot

Factual Information

History of Flight

Approach
Fuel exhaustion

Approach-IFR final approach
Loss of control in flight (Defining event)

Uncontrolled descent
Collision with terr/obj (non-CFIT)

On April 22, 2019, at 0851 central daylight time, a Beech 58 airplane, N501CE, was substantially damaged when it was involved in an accident near Kerrville Municipal Airport (ERV), Kerrville, Texas. The pilot and five passengers died. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.

According to airport surveillance video from West Houston Airport (IWS), Houston, Texas, the pilot accomplished an abbreviated preflight inspection of the airplane, during which he appeared to visually check the exterior left-wing fuel level sight gauge but not the right-wing fuel level sight gauge; the pilot did not sump any of the 10 fuel drains. The pilot returned to the terminal to meet the passengers, and after both engines were started, the airplane departed about 0730.

According to air traffic control (ATC) and automatic dependent surveillance-broadcast (ADS-B) information, after departing IWS, the pilot obtained an instrument flight rules (IFR) clearance and was instructed to climb to 3,000 ft mean sea level (msl). The flight proceeded toward ERV, climbing to a cruise altitude of 6,000 ft msl. About 0824, the pilot requested the RNAV (GPS) instrument approach for runway 12 and was cleared for the approach via a procedure turn and to descend to 4,000 ft. About 0833, the pilot reported his descent to 4,000 ft and the controller advised that "bases were 2,400," which the pilot acknowledged.

About 0839, the pilot was cleared for the GPS instrument approach to runway 12 and instructed to maintain 4,000 ft to the initial fix for the approach (OBUCO) (see figure 1). Once the airplane was in-bound to the airport, about 0843, the controller directed the pilot to switch to the ERV advisory frequency, which was unmonitored. The GPS instrument approach profile for runway 12 included a descent to 3,300 ft msl at 5.3 nautical miles from the runway.

Figure 1. A Google Earth aerial view of terrain near the accident site with overlaid ADS-B data and approach information.

According to ADS-B data, the airplane maintained an altitude of 3,900 ft until about 0844:59, when it began a steady descent; the airplane was about 13 miles from the runway. Data from the airplane's engine data monitor (EDM) indicate that the left engine lost power about 0845 followed by the right engine about 10 seconds later. ADS-B data indicated that the airplane steadily descended well below the approach profile.

EDM data indicated that, about 40 seconds after losing power, the left engine regained near full power, which it maintained until the end of recorded EDM data about 0851. ADS-B data indicated that the airplane slowed below the minimum controllable airspeed (Vmc) of 83 knots as it descended from about 500 to 300 ft agl, and the descent rate decreased. A witness on the ground saw the airplane on final approach at a low altitude, when it entered a right turn, began a right spiral, and disappeared behind a ridge line. 

Pilot Information

Certificate: Airline Transport; Private
Age: 65, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 10/10/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 11/01/2018
Flight Time:  (Estimated) 5671 hours (Total, all aircraft), 2409 hours (Total, this make and model), 5565 hours (Pilot In Command, all aircraft), 106 hours (Last 90 days, all aircraft), 59 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft) 

A flight instructor who frequently flew with the pilot and conducted his most recent flight review stated the pilot's mechanical flying skills were very good but, on occasion, his understanding of technical issues was not as strong. The flight instructor noticed a few times when the pilot did not perform well during unexpected in-flight issues. He stated the pilot normally planned to land with at least 1 hour of fuel remaining.

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N501CE
Model/Series: 58
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: TH-1888
Landing Gear Type: Retractable -
Seats: 6
Date/Type of Last Inspection: 08/27/2018, Annual
Certified Max Gross Wt.: 5500 lbs
Time Since Last Inspection: 105 Hours
Engines: 2 Reciprocating
Airframe Total Time: 3834 Hours at time of accident
Engine Manufacturer: Continental
ELT: C91A installed, not activated
Engine Model/Series: IO-550C
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None

Fuel System

The airplane's fuel system comprised three fuel cells and one wet tip tank for each wing. Total fuel capacity for the airplane was 200 gallons; the three fuel cells in each wing held a total of 83 gallons of usable fuel and 3 gallons of unusable fuel, and the wet tip tank held 14 gallons of fuel, all of which was usable.

The wing fuel cells and wet tip tanks were interconnected so that all usable fuel was available with the fuel selector valve for each wing in the ON position and supplying fuel to its respective engine. The CROSSFEED position on the fuel selector was only to be used in an emergency. Each wing had two flush-type fuel filler caps: one located in the outboard end of each outboard leading-edge fuel cell and one in the wet tip fuel tank.

Fuel quantity was measured by float-type units that electrically transmitted a single indication for each wing system to fuel quantity indicators in the cockpit. The fuel quantity indicator would show full until the respective wing fuel cells contained less than about 75 gallons. According to an American Bonanza Society (ABS) technical representative, the three fuel quantity transmitters in each wing were wired in series with one another. Fuel quantity would be at least 75 gallons at 199 ohms and 3 gallons of unusable fuel at 0 ohms. In this range, the resistance value of the transmitter circuits in each wing was designed to be directly proportional to the amount of fuel.

The caution range (yellow band) on the cockpit fuel quantity indicators was from 0 to 1/8th of the amount indicated by the fuel quantity indicator (about 9.33 gallons usable per wing).

Fuel level sight gauges on the leading edge of each wing only indicated fuel levels from 40 to 60 gallons per wing. It was not possible to use a dipstick to check fuel quantity due to each wing's dihedral and the location of the filler caps.

Fueling Information

Fueling of an exemplar 1999 Beech 58 showed that when the airplane's wing fuel cells were filled as much as possible from the inboard wing filler caps, the wet tip tanks became partially filled because of the wing's dihedral, resulting in a total of 188 gallons of fuel (182 usable) on board. In order to fill the wet tip tanks, about 6 gallons of fuel would be added to each tip tank through the wet tip tank fuel filler cap.

Fuel Consumption

The accident airplane's EDM indicated that the airplane consumed about 28 gallons of fuel per hour (gph) during the accident flight while at cruise power. According to the airplane's pilot operating handbook (POH), the airplane consumed about 34 gph of fuel at maximum cruise power (200 kts) and about 18 gph at economy cruise power (163 kts).

Weight and Balance

The airplane's maximum gross weight was 5,500 lbs. Based on passenger weights provided by the medical examiner, the airplane's takeoff weight was calculated as 5,598 lbs with 50 gallons of usable fuel and 5,526 lbs with 38 gallons of usable fuel. The airplane's center of gravity was 86.7 inches at the time of the accident; the acceptable cg range with low fuel was 77.7 to 86.2 inches.

Airplane Performance

The Beech 58 engine-out procedure in the POH directed flaps to be retracted and the propeller of the inoperative engine to be feathered. The airplane's performance charts indicated a one-engine-inoperative climb capability of about 300 feet per minute (fpm) with the inoperative engine's propeller feathered, flaps up, and a gross weight of 5,300 lbs.

A flight operations pilot for the airplane manufacturer who regularly performed single-engine drag demonstrations reported that lowering flaps from 0° to 15° with one engine inoperative resulted in a 150-fpm decrease in climb rate and an unfeathered propeller configuration resulted in a 400-fpm decrease in climb rate.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: KERV, 1617 ft msl
Distance from Accident Site: 6 Nautical Miles
Observation Time: 0855 CDT
Direction from Accident Site: 121°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 1200 ft agl
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 17 knots
Turbulence Type Forecast/Actual: None / None
Wind Direction: 170°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.04 inches Hg
Temperature/Dew Point: 18°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Houston, TX (IWS)
Type of Flight Plan Filed: IFR
Destination: Kerrville, TX (ERV)
Type of Clearance: IFR
Departure Time: 0729 CDT
Type of Airspace: Class E 

The 1,200 ft agl ceiling reported by the ERV automated weather observation system correlated to a ceiling at the accident site of about 950 ft agl. A pilot who flew an approach to ERV reported 2,400 ft msl cloud bases, which correlated to a ceiling at the accident site of about 550 ft agl. 

Airport Information

Airport: Kerrville Muni/Louis Schreiner (ERV)
Runway Surface Type: Asphalt
Airport Elevation: 1616 ft
Runway Surface Condition: Dry
Runway Used: 12
IFR Approach: Global Positioning System; RNAV
Runway Length/Width: 6004 ft / 100 ft
VFR Approach/Landing: Full Stop 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude: 30.037500, -99.185833

The airplane impacted a rocky ravine about 120 yards from the final radar data point and about 6 miles from the airport. There was no postimpact fire and the airplane came to rest upright on a heading of 246° (see figure 2). The wreckage was contained within the footprint of the airplane, indicating a low forward groundspeed. Elevation at the accident site was 1,868 ft msl and trees about 40 yards northeast were the nearest obstructions.

Figure 2. Photograph of an aerial view of the accident site

All flight control surfaces were present and flight control cable continuity was established from the tail surfaces to the aft empennage, where the cables were bound by the cabin floor, which was crushed by impact forces. Aileron and aileron trim tab cable continuity was established from the control surface to the wing root.

About 1 gallon of fuel was drained from the left-wing fuel cells on the day of the accident. When the left wing was lifted at the wing tip on the day after the accident, about 1 cup of fuel was observed in the left-wing fuel cells and about 1 cup of fuel drained from a breached area near the engine nacelle. No fuel was observed in the right-wing wet tip tank or the right-wing fuel cells. All fuel tank caps were secured. There was no evidence of fuel blight on the area surrounding the airplane.

Four of the six fuel cells were in their installed position with no obstructions. The left-wing box cell was loose at the top due to impact damage and the right-wing inboard leading-edge fuel cell was in the installed position, except where cut by recovery personnel.

The left fuel selector was near the ON position; it was positioned about 1/4 toward OFF. A small amount of fuel was found in the left fuel selector valve and fuel strainer. The right fuel selector was in the ON position. No fuel was present in the right fuel selector valve or fuel strainer. No water was detected.

Postaccident resistance testing of the six fuel quantity transmitters revealed a total transmitter resistance at the empty setting of 13.7 ohms in the left wing and 14.6 ohms in the right wing. Factory specification resistance for each of the six individual transmitters was 0 to 0.5 ohm at the empty setting.

According to the ABS technical representative, the additional resistance found in the six transmitters corresponded to a reading of about 5 gallons more than the actual fuel for each wing, (or about 1/16 tank more than the actual amount shown on each fuel quantity indicator), which would equal about 20 to 24 minutes of flying time. Impact damage precluded testing for additional resistance in the fuel quantity circuits.

Both fuel quantity gauges and engine fuel flow transducers were tested, with no anomalies noted. Testing reports are in the docket for this investigation.

The landing gear were in a retracted position. The left-wing flap actuator position corresponded to a 15° flap setting; the right-wing flap actuator was fractured. Both electric fuel boost pump switches were at the high position. The throttle, propeller, and mixture controls were all near the full-forward position.

The propeller for the left engine separated from the engine during the impact sequence. Blades 'A' and 'B' remained attached to the hub. Blade 'A' exhibited leading-edge burnishing and was bent aft at the tip. Blade 'B' exhibited leading-edge gouging, chordwise and spanwise scratching, and was curled forward from the root. Blade 'C' was located under the left-engine cowling and curled aft at the tip with gouging.

The propeller for the right engine remained attached to the engine and all three blades remained in the hub. Blade 'A' was straight with minimal damage. blade 'B' was bent aft at the root, and blade 'C' was straight, with light leading-edge gouging along the outer half of the blade. The position of the three blades was not feathered and was in or near the low-pitch stop position.

Both engines were examined, and no engine anomalies were observed that would have prevented normal operation. 

Medical And Pathological Information

An autopsy of the pilot was performed at the Travis County Medical Examiner's Office, Austin, Texas. The cause of death was blunt force injuries. The autopsy found atherosclerotic arterial disease, including greater than 90% stenosis of the right coronary artery, greater than 90% stenosis of the left anterior descending coronary artery, 60% to 70% stenosis of the left main coronary artery, 40% to 50% stenosis of the left circumflex coronary artery, and 20% to 30% stenoses of the right and left coronary ostia (all percentages approximate). The autopsy found no other significant natural disease.

Toxicology testing of the pilot's tissue and fluid samples performed at the Federal Aviation Administration (FAA) Forensic Sciences Laboratory detected naproxen, fexofenadine, azacyclonol, rosuvastatin, and irbesartan in blood and urine. These drugs are not considered impairing.

According to the pilot's girlfriend, the pilot was well rested and in good health, both mentally and physically, before the accident flight. Airport surveillance video showed that the pilot appeared to be alert during the hour before the flight. 

Additional Information

EDM Data

A J.P. Instruments EDM-760 was recovered from the wreckage and downloaded. Data from the last 10 flights, including the accident flight, were recorded at 6-second intervals; these data included fuel flow, fuel used, exhaust gas temperatures, cylinder head temperatures, and shock cooling rate of the two engines.

After fuel flow to the left engine decreased to 0 gph where it remained for about 40 seconds, fuel flow increased to about 32 gph and remained near 30 gph for the remainder of the recorded data. After fuel flow to the right engine decreased to 0 gph, it remained near 0 until about 4 minutes before the end of the data, when it increased to about 15 gph for a few seconds and then returned to 0. About 3 minutes before the end of the data, the right engine fuel flow rose to between 2 and 6 gph for about 30 seconds and then returned to 0, where it remained for the remainder of the recorded data.

Total fuel used on the accident flight was about 42 gallons, with the left and right engines consuming 22 and 20 gallons, respectively. Based on the left engine restarting and running at 30 gph for about 6 minutes, the total fuel used at the time of the power loss of both engines was about 39 gallons.

Total fuel used between the fueling on April 14 and the accident flight, was 214.7 gallons, with the left and right engines consuming 108 and 106.7 gallons, respectively.

Performance Study

As stated above, the wreckage examination found that the flaps were positioned at 15° and the right engine propeller was not feathered. The NTSB's performance study found that had the pilot feathered the propeller of the inoperative right engine and retracted the flaps, the resulting reduction in drag would have been sufficient to maintain the airplane's glideslope to the runway assuming that the left engine maintained thrust.

Fuel Planning

For IFR flight plans, 14 CFR 91.167 requires enough fuel to reach the destination airport and an alternate airport, plus 45 minutes of flight time at normal cruising speed.

Before departure, the pilot planned several routes from IWS to ERV using the ForeFlight mobile flight-planning application. The pilot checked airport information at ERV and two airports between IWS and ERV (the airports were closer to IWS than ERV). He did not check information for alternate airports in the vicinity of ERV.

The pilot filed an IFR flight plan using flightplan.com, which included a navigation log that provided fuel calculations based on information entered by the pilot. Estimated fuel consumption for the flight was about 38 gallons, which included 5 gallons of taxi fuel; the navigation log included fuel required for the IFR flight of about 58 gallons, including a 45-minute fuel reserve at normal cruising speed of 20.3 gallons. The navigation log did not include fuel for an instrument approach at ERV, and an alternate airport was not designated. Postaccident calculations of the fuel required for the IFR flight indicated that a minimum of 67 gallons would be required, which included fuel for an instrument approach to ERV, 6 gallons of fuel for an instrument approach at the closest alternate airport, and 20 gallons of reserve fuel.

Flight Planning Log

The pilot used a flight-planning log to record starting and ending fuel for each flight. The log showed the date, departure and landing locations, the tachometer start and stop times, the total flight time, and the beginning and ending fuel (in gallons) for each flight. The pilot likely based the fuel consumption information on the EDM data. Figure 3 shows the six previous flights, beginning on April 14, as well as the accident flight.


Figure 3. Pilot's Flight-Planning Logs

According to the fueling company manager at IWS, the pilot would typically order fuel over the telephone and would not be present when the airplane was fueled. The pilot's normal fuel order was to fill only the wing fuel cells (not the wet tip tanks). The pilot's fuel order 8 days before the accident (on April 14) was taken over the phone and transcribed on a service request form as "T/O x 4." In postaccident interviews, the fueler stated that he understood the order as written to be a "top off" of the wing fuel cells and wet tip tanks for both wings and recalled fueling the airplane until the main fuel cells and wet tip tanks were completely full. The fuel receipt from the IWS fueling company on the evening of April 14 indicated that 113 gallons of fuel were added.

Before the fueling on April 14, the pilot's fuel log indicated an ending fuel of 60 gallons (see the top of figure 3). As shown in figure 3, the pilot recorded 194 gallons as the starting fuel for the first flight on April 15. However, based on the fuel quantity indicated on the fuel receipt, the total fuel should have been recorded as 173 gallons (60 gallons on the fuel log plus the 113 gallons on the fuel receipt); thus, the pilot's fuel log indicated a starting fuel load 21 gallons more than it should have been on April 15.

The log indicated that the ending fuel for the flight before the accident flight, on April 17, was 50 gallons; however, it appears that the pilot wrote 54 as the beginning fuel for the accident flight (highlighted at bottom of figure 3). The investigation was unable to determine the reason for this difference given that no fuel order or fuel receipt for the period between April 17 and the day of the accident was located, and the fueling company at IWS does not offer a self-service fueling option.

Given the noted errors above, the investigation used the EDM fuel consumption data to determine how much fuel was actually onboard the airplane after the 113 gallons were added on April 14. Based on the confirmed fueling of 30 gallons on April 17 and the EDM fuel consumption data for the flights between April 14 and the accident, the investigation determined that usable starting fuel on April 15 was about 182 gallons, which was 12 gallons less than the amount the pilot recorded.

Spin Avoidance and Recovery Guidance

In March 2006, Raytheon Aircraft Corporation (RAC) issued Safety Communiqué No. 249, "Spin Avoidance and Spin Recovery Characteristics," which includes the following information:

A spin can occur whenever an airplane is stalled and is subject to yaw input. Yaw input can be provided by rudder, asymmetric power, aileron, p-factor, or any combination of these forces. Any time asymmetric power is allowed to continue through spin entry and into a developed spin, a dangerous and possible unrecoverable spin (to the left or right) could be encountered.

According to the FAA Airplane Flying Handbook:

No multi-engine airplane is certified for spins, and their spin characteristic is generally poor. As very few twins have been spin tested (none are required to), the recommended spin recovery techniques are based only on the best information available. The departure from controlled flight may be quite abrupt and possibly disorienting.

FAA Advisory Circular 61-67C, "Stall and Spin Awareness Training," includes the follow information:

The center of gravity has a significant effect on stability and stall/spin recovery. As the center of gravity is moved aft, the amount of elevator deflection needed to stall the airplane at a given load factor will be reduced. An increased angle of attack will be achieved with less elevator control force. This could make the entry into inadvertent stalls easier, and during the subsequent recovery, it would be easier to generate higher load factors due to the reduced elevator control forces.

Although the hilly, rocky, and wooded terrain near the accident site offered limited forced landing options, a plateau with a dirt road was in front of the airplane before the right turn at the end of the flight.

American Bonanza Society Article

After the accident, the June 2019 issue of American Bonanza Society Magazine published an article reminding pilots of prudent actions when refueling and noting the following:

Whenever possible, personally fuel your airplane, or watch it being refueled. Ensure that the proper type and quantity of fuel is added in the tanks you want it put into. Compare the fuel bill to your expectations. Check the amount of fuel that was added against the amount you thought you would need. If there is a big discrepancy, figure it out, whether less fuel than you expected was put in or you needed more than you thought because your fuel tracking was flawed on prior flights.

Ensure your fuel gauges are accurate. Our Australian friends are required to have their fuel gauges calibrated .... and a placard next to the gauges that show the instrument error for each marking on the gauges, similar in concept to a compass correction card. It is possible for our fuel gauges to be reliable.

Fuel Quantity System Maintenance Guidance

The Beech 58 annual inspection guide specified checking "for proper operation and unusual fluctuations" of fuel quantity gauges. The Beech maintenance manual recommended fuel quantity transmitters be overhauled or replaced as necessary.

In general, no FAA regulations and little guidance addressed periodically checking the accuracy of fuel quantity indicators. In response to a reported safety concern, a 2003 special airworthiness information bulletin (SAIB) recommended owners of Cessna 100, 200, 300, and 400 airplanes perform calibration checks of both the empty and full positions of their airplanes' gauging system at the next inspection then at 5-year intervals.


The NTSB is aware that, based on this accident and other fuel-related accidents involving resistance-type fuel quantity gauging systems, the FAA is working on an SAIB addressing all aircraft with such systems.











Location: Kerrville, TX
Accident Number: CEN19FA124
Date & Time: 04/22/2019, 0851 CDT
Registration: N501CE
Aircraft: Beech 58
Injuries: 6 Fatal
Flight Conducted Under: Part 91: General Aviation - Business 

On April 22, 2019, at 0851 central daylight time, a Beech 58 airplane, N501CE, impacted terrain during approach to Kerrville Municipal Airport (ERV), Kerrville, Texas. The pilot and five passengers were fatally injured, and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. Day instrument meteorological conditions prevailed for the flight, which departed on an instrument flight rules flight plan from West Houston Airport (IWS), West Houston, Texas, at 0730.

According to preliminary air traffic control (ATC) information, the airplane approached ERV and was cleared to fly the RNAV (GPS) Approach Runway 12. The controller advised the pilot that the cloud bases were reported at 2,400 ft mean sea level (msl) and subsequently directed him to switch to the common traffic advisory frequency at ERV. While on final approach, the airplane descended and the last location recorded by ATC was about six miles prior to Runway 12, about 2,050 ft msl and about 65 knots groundspeed.

Three witnesses noticed the airplane flying at a low altitude and a spiral descent. The airplane impacted into a rocky ravine with a low forward groundspeed and came to rest upright. The wreckage was contained within the footprint of the airplane and there was no post-impact fire. The airplane was retained for further examination at the recovery location.

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N501CE
Model/Series: 58
Aircraft Category: Airplane
Amateur Built: No
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KERV, 1617 ft msl
Observation Time: 0855 CDT
Distance from Accident Site: 6 Nautical Miles
Temperature/Dew Point: 18°C / 16°C
Lowest Cloud Condition:
Wind Speed/Gusts, Direction: 11 knots / 17 knots, 170°
Lowest Ceiling: Overcast / 1200 ft agl
Visibility:  10 Miles
Altimeter Setting: 30.04 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Houston, TX (IWS)
Destination: Kerrville, TX (ERV)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 6 Fatal
Latitude, Longitude: 30.037500, -99.185833


(clockwise from upper left) Jeffrey Weiss, Angela & Stuart Kensinger, Mark Scioneaux, Marc Tellepsen and Scott Reagan Miller.





HOUSTON - Six people were aboard a small airplane traveling from Houston to Kerrville on Monday when it crashed into a rocky patch of land just miles from its destination.

All six people were killed.

Authorities identified the victims as:

Jeffrey Carl Weiss, 65, of Houston (pilot)
Stuart Roben Kensinger, 55, of Houston
Angela Webb Kensinger, 54, of Houston
Mark Damien Scioneaux, 58, of Houston
Scott Reagan Miller, 55, of Houston
Marc Tellepsen, 45, of Houston

As the investigation into the crash begins, stories are being shared about the victims. Here’s what we’ve learned about them.

Pilot Jeffrey Weiss has several planes, three of which are kept at West Houston Airport, including the twin-engine Beechcraft BE58 plane that crashed Monday, according to the airport manager.

The manager said Weiss has flown for about 15 years and averaged about 40 hours of flight time a month, which equates to about 500 hours a year.

Weiss was well-known for his giving nature, the manager said. A majority of Weiss' flights were charitable acts -- such as picking up kids and people with medical issues and helping veterans travel. He also took part in a program to pick up stranded pilots.

The manager said he heard Weiss on the radio about 7:30 a.m. Monday 7:30 a.m. saying he was turning right and heading west.

Angela Kensinger was the women’s lacrosse coach at St. John’s High School in River Oaks, and her husband Stuart Roben Kensinger was in real estate.

People who knew the couple said they were going to look at property they owned in the area and were preparing to make renovations.

“There’s going to be a lot of heartache over the loss of these too,” said Meg Rice, a longtime neighbor of the Kensingers.

Mark Damien Scioneaux was the husband of Houston Ballet artistic director Stanton Welch, and was a landscaping architect at Tellepsen Landscaping Services for the past 11 years, according to LinkedIn.

Welch told KPRC2, "Mark was a deeply loved man. He was generous and creative and will be missed. He was a landscape architect who won many awards and was deeply embedded in the community. Houston was his home and he loved this city."

A funeral service is planned for Saturday at 1 p.m. and will be open to family and friends.

The Houston Ballet sent KPRC2 a statement that read, "Words cannot express the sadness our Houston Ballet family feels over the sudden loss of Mark Scioneaux and the other 5 lives lost in the tragic plane accident yesterday. We will dearly miss Mark, the loving husband of our artistic director, Stanton Welch AM. He was a true friend to each of us in our tight-knit ballet family. He exuded a genuine warmth, with a kindness and big heart that defined him. Simply put, everyone loved Mark. And, we will work to keep his memory, his love and his kind spirit alive."

According to LinkedIn, Marc Tellepsen also worked at Tellepsen Landscaping Services. He was listed as the operational manager. A photo of Tellepsen is not yet available for publication.

Scott Reagan Miller had been an architect in Houston for more than 20 years.


Original article can be found here ➤ https://www.click2houston.com


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HOUSTON, Texas (KTRK) -- A Houston entrepreneur, an investment banker active in local charities, and the husband of Houston Ballet's artistic director are among the dead in a plane crash in Kerrville. 

The family of Marc Tellepsen confirms with ABC13 Eyewitness News that he was killed when the twin-engine Beechcraft BE58 he was traveling in crashed into the rocky terrain of the Texas Hill Country. 

Tellepsen, 45, was the owner of landscape architect firm Tellepsen Landscaping. 

He was also related to the family that founded the renowned construction firm Tellepsen Builders. 

His family released this statement: 

The family of Marc Tellepsen is extremely grateful for the outpouring of support from our friends, family and fellow Houstonians at this incredibly difficult time. We hope you understand our need for privacy as we grieve for the loss of our husband, father, beloved family member and friend. 

Mark Scioneaux, 58, is the husband of Houston Ballet artistic director Stanton Welch, and according to his LinkedIn page, worked in architecture and planning for Tellepsen Landscaping. 

"Words cannot express the sadness our Houston Ballet family feels over the sudden loss of Mark Scioneaux and the other 5 lives lost in the tragic plane accident yesterday. We will dearly miss Mark, the loving husband of our artistic director, Stanton Welch AM. He was a true friend to each of us in our tight-knit ballet family. He exuded a genuine warmth, with a kindness and big heart that defined him. Simply put, everyone loved Mark. And, we will work to keep his memory, his love and his kind spirit alive," said a statement from the Houston Ballett. 

Jeffrey C. Weiss was a senior vice president for investments at Raymond James and Associates in Houston. The Texas Department of Public Safety says the 65-year-old Weiss, who co-owned the Beechcraft BE58, was at the controls when the aircraft went down just before 9 a.m. Monday while approaching Kerrville Municipal Airport, about 70 miles northwest of San Antonio. 

DPS Sgt. Orlando Moreno identified the other victims as 55-year-old Stuart Roben Kensinger; 54-year-old Angela Webb Kensinger; and 55-year-old Scott Reagan Miller. 

St. John's School Headmaster Mark Desjardins sent a message about the deaths of Stuart and Angela. Stuart was a graduate of St. John's in 1981, and Angela was the school's long time varsity girls' lacrosse head coach. 

"This is shocking news for our entire community. At school tomorrow, we will have grief counselors available throughout the day for any student in need of support and guidance. Our thoughts and prayers are with all members of the Kensinger family, especially their son, Philip '16, and many individuals within our community who were close with Angie and Stuart. There are no words to describe the overwhelming sense of grief that we all feel over this devastating and sudden loss of two very close friends of this community," Desjardins wrote. 

Weiss owned the plane with his friend and fellow pilot Charles Morina. He said Weiss loved to fly and the pair volunteered their time transporting sick people from remote regions to Texas hospitals for Angel Flight. 

The Tellepsen family say they believe an architectural client chartered the plane, and were taking Tellepsen and Scioneaux on a short trip to survey some property when it crashed. 

Late Monday, the Tellepsen family issued this statement: 
The family of Marc Tellepsen is extremely grateful for the outpouring of support from our friends, family and fellow Houstonians at this incredibly difficult time. We hope you understand our need for privacy as we grieve for the loss of our husband, father, beloved family member and friend. 

Story and video ➤ https://abc13.com


Jeffrey C. Weiss has several planes, three of which are kept at West Houston Airport.


Bob Fuller
Fuller said he heard about the crash Monday morning from a friend who told him Weiss was at the controls.


HOUSTON, Texas - Six people died Monday in a plane crash on a private ranch in Kerrville, according to officials.

The plane departed from the West Houston Airport and crashed just before 9 a.m. while preparing to land at Kerrville Municipal Airport, which is about 6 miles away from the crash scene.

Officials said all six adults aboard the plane were killed. Here are the people who were killed:

Jeffery Carl Weiss, 65, of Houston (pilot)

Stuart Roben Kensinger, 55, of Houston

Angela Webb Kensinger, 54, of Houston

Mark Damien Scioneaux, 58, of Houston

Scott Reagan Miller, 55, of Houston

Marc Tellepsen, 45, of Houston

KPRC2 learned the plane is registered to Weiss, a successful Houston businessman and experienced pilot.

Weiss had logged more than 5,000 hours in the air, according to officials.

Officials do not yet know what caused the crash.

Weiss made his living as a personal wealth manager for the Raymond James firm, but his passion was flying and he used his flying skills to help others.

His friend Bob Fuller said he heard about the crash Monday morning from a friend who told him Weiss was at the controls.

"I got a call from a friend of mine who verified ... it was Jeff," Fuller said.

Fuller said Weiss volunteered his time for an array of charities: Providing flights for medical and humanitarian emergencies, for special needs kids, and supported both the Lone Star flight museum and the 1940 Air Terminal Museum at Hobby Airport.

Fuller said Weiss was the best pilot he'd ever seen.

"He's as meticulous a pilot as I've ever known," Fuller said. "Exceedingly safe, safety conscious."

Weiss also helped Fuller put on his Keels and Wheels charity event in Seabrook each year to aid abused children, giving both his time and money.

"I loved the man, I'll tell you that. He was generous to a fault. He wanted to support our charity any way he can and one of those was if I wanted to fly to Detroit to talk to General Motors, 'Call me first.'"

As Fuller mourns his friend, he is anxious to learn more about exactly what happened to the veteran pilot.

"ATC says he lost airspeed, and he was using instrument approach and he went down. I don't know if it was (the) engine. I have no clue," Fuller said.

Story and video ➤ https://www.click2houston.com


Kerr County Sheriff Rusty Hierholzer walks along Sheppard Rees Road, near the location where a Beechcraft 58 Baron crashed just outside Kerrville on private land, on April 22, 2019.



Kerr County Sheriff Rusty Hierholzer, center, makes a phone call, April 22, 2019, where his deputies guard the entrance to a private road near Kerrville, Texas, where a  Beechcraft 58 Baron crashed earlier in the day, killing all six people on board.

Robert Hurt
Local resident and former pilot Robert Hurt said he was puzzled why the plane was so far out on its final approach to the airport. He said weather conditions were good.


HOUSTON - Jeffrey C. Weiss has several planes, three of which are kept at West Houston Airport.

His fleet includes the plane that crashed Monday on a private ranch in Kerrville.

He and five others died in the crash, according to officials.

The plane departed from the West Houston Airport and crashed just before 9 a.m. while preparing to land at Kerrville Municipal Airport, which is about 6 miles away from the crash scene.

Officials said all six adults aboard the plane were killed.

The airport manager of West Houston Airport said it was a Beechcraft 58 Baron that crashed. The manager said it's a very popular aircraft that can seat six people.

The manager said Weiss has two other airplanes at the airport and has flown there for about 15 years.

Weiss is well-known for his giving nature and the manager said Weiss averaged about 40 hours of flight time a month, which equates to about 500 hours a year.

The manager said a majority of Weiss' flights were charitable acts -- such as picking up kids and people with medical issues and helping veterans travel. He also took part in a program to pick up stranded pilots.

A friend of Weiss said Weiss was behind the controls.

"If you were a friend and wanted to go from here to the Valley for a weekend hunting trip and called Jeff, 'Any chance you can take me down there?' He'd say, 'Sure, I love to fly, I'll take you,'" Bob Fuller said.

The manager said he heard Weiss on the radio Monday morning around 7:30 saying he was turning right and heading west.

He said Weiss flew a lot and last flew on Saturday. He said he's an excellent pilot and that they've flown together.


Story and video ➤ https://www.click2houston.com



Construction worker Richard Hall describes the last moments of before a Beechcraft 58 Baron crashed near Kerrville. He said plane flew over his work site. His co-workers said the engine cut out.



Federal investigators are on the scene of a deadly plane crash in the Texas Hill Country. The Beechcraft 58 Baron went down shortly before 9:00 a.m. about six miles northwest of Kerrville Municipal Airport.

Texas Department of Public Safety Sgt. Orlando Moreno said the plane crashed on a private ranch, killing all five passengers and the pilot.

The FAA was investigating the exact cause of the crash.

Construction worker Richard Hall said he was on a Bobcat vehicle when he saw the plane fly about 300 or 400 feet over his worksite. He said electricians working with him said they heard the engine cut out.

Local resident and former pilot Robert Hurt said he was puzzled why the plane was so far out on its final approach to the airport. He said weather conditions were good.

"No need for instruments, that I could tell," he said. "I am puzzled why they were this far out. You would not need to come this far out," a reference to the final approach.

The plane reportedly flew out of West Houston Airport. It was unclear if Kerrville was its scheduled final destination.

Original article can be found here ➤ https://www.tpr.org




KERRVILLE, Texas — KERRVILLE, Texas-- Six people have reportedly been killed in a plane crash in Kerrville Monday, the Texas Department of Public Safety has confirmed to KENS 5.

According to DPS Sergeant Orlando Moreno, the crash took place just before 9 a.m. near the Kerrville Municipal Airport.

Sgt. Moreno said all of the six occupants on board died in the aircraft that had departed earlier this morning from West Houston Airport outside Houston.

Sgt. Moreno said that the Beechcraft 58 Baron crashed into a private ranch while attempting to land at the Kerrville Municipal Airport. The ranch owner told KENS 5 planes fly over his property three to four times a day since they're so close to the airport.

It was not clear if there was a mayday call made prior to the crash. Sgt. Moreno said that they were not releasing the victim's identities and would be turning that decision over to The Federal Aviation Commission, the main investigating agency.

Richard Hall was doing some construction work when told KENS 5 a plane few just above his head by the time he turned around, the plane had crashed.

"It was just shocking and to see something like kind of slow motion go down, you think you're going to have more time to get over there and find the plane, maybe help some survivors," Hall said. "According to DPS, they had gone down so fast, there was no chance." 

According to KENS 5 sister station KHOU, the plane is registered to Jeffery Weiss of Houston. Sources told KHOU he died in the crash.

Along with the FAA, DPS and NTSB were assisting in the investigation.

Story and video ➤ https://www.kens5.com

19 comments:

  1. It looks like the plane was on the RNAV approach to runway 12 at KERV, and went through some significant airspeed fluctuations after the procedure turn at OBUCO.

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  2. Speculation is worth a teaspoon of warm gopher drool - but it can be interesting and develop our thinking.
    One blade of the prop on #2 engine is not bent or damaged (apparently).
    No fire.
    Not much ground scar is evident.
    Flat spin after #2 stopped for whatever reason?

    RIP to those who perished, condolences to their families and to the first responders.

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  3. 6 adults in a 58 is cramped. Plus, C.G. Is dicey. I wonder if he was past the aft limit which would aggravate controllability with an engine out.

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  4. I agree with the above poster, looks like the right engine was shut down and prop feathered, likely got too slow and stalled/spun it in, as the wreckage is fairly contained in one area indicating minimal forward motion.

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  5. 6 large adults (judging by the photos of the deceased) seems a bit much. I wonder if he took on less fuel to make the max gross weight and ended up running out of fuel short of the runway (lack of post-crash fire). If the right engine quit, the left engine may have still been running on fumes and that plane could have been a monster on one engine at that weight. I agree, most likely a stall/spin but appears the plane pancaked in and not straight down as lack of damage to the nose of the plane. The aerial video of the wreckage appears to show the entire top of the fuselage cabin area torn off (maybe it was cut off by first responders to get to the victims). NTSB will get it figured out, RIP to all lost.

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  6. spun in, flat impact, single engine ops perhaps, could be reason for the airspeed decay..RIP

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  7. Doesn't appear to be much damage to either prop

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  8. According to FlightAware he got very slow after turning inbound, I saw 79 kts on last radar return.

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  9. If you look at his track and flight plan, he was inbound on the RNAV 12 approach into Kerville. He descended to 4,000' and crossed the IAF and did a teardrop entry into the approach. He maintained altitude as he made a right turn and got on the localizer. He starting having a tough time staying on the 124 degree heading as he descended (autopilot issue?). His next waypoint on the inbound route was LAVIC (which is 5 miles from the airport) and he should have been at or above 3,300' there. However, he descended to 2,300' .. 2 miles before he arrived at LAVIC (too low), but was in level flight and had enough airspeed to maintain flight there.
    Don't know if he couldn't see the runway or maybe was having an mechanical issue, but he never got stabilized and was too low too soon on the inbound approach.
    My "guess", and that's all anybody has without more information ... is that he was distracted on the approach trying to stay on the localizer and descended too low. He was trying to find the runway and let his airspeed bleed off too much and he stalled it.
    OR .... It is the hill country and the airport elevation is 1,600' and he was flying the last mile at 2,100' before it went off radar. Don't know the area, but if he was too low, could he have hit or scraped something (tree top) and that caused the chain of events that led to the pancake stall mishap?


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  10. Some good observations above. When twins crash in descent I often suspect a fuel issue. One thing I would add to those comments above is that an aft CG is more favorable in one engine inoperable situations as far as VMC is concerned. If within max gross a B58 should easily maintain a glidelsope descent or better. It does make one wonder if the tanks ran dry. :/

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  11. Directional control in multi engine airplanes with one engine inoperative is more difficult at aft CG vs. forward due to shorter arm.

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  12. Given the witness accounts and some quick internet calculations found on a Beech model 58, I'm going with fuel exhaustion on this one. I think given the weight of all 6 occupants(not including any baggage), the pilot only had about 60 gals in the tanks to make max gross weight at takeoff or enough for 1 1/2 hrs flying time with a 1/2 hr reserve. The Flightaware flight track shows 1:22 minutes not counting start-up,taxi,or run-up. I'm thinking when he did his procedural turn inbound, it un-ported the fuel pickup in the tank causing it to suck air and leading to the right engine to quit. The plane may have been hard to control at that weight or maybe the pilot just got distracted, got too slow and stalled & spun in. RIP to the pilot and my condolences to the families of the deceased.

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  13. Flat impact, guess one of the engines failed and the CG was near the limit, RIP.

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  14. Agree completely with the comments herein. I too believe in engine failure, probably due to fuel exhaustion and then an issue even with shut-down/feathering & 5% bank to good engine, the lower altitude and aft CG became too much to handle. A slight mishandling and over-limit payload could have induced a stall, leading to flat spin, which was unrecoverable. Explains the lack of extended debris field, final location, lack of nose or lateral gear impact, and absence of post-impact fire. RIP to Jeff and the rest of the souls aboard. Fine pilot and an even better man. Rest easy my friend.

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  15. It has been more that a week since the accident and I still feel like my heart has been ripped out with a back hoe. For those of us that knew Jeff suffice it to say that this ending is not what he would have wanted for his friends or for himself. God bless you Jeff, you were a good man.

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  16. The road to hell is paved with good intentions.

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  17. Similar accident in a Navajo a year or so ago...fuel exhaustion, two professional couples lost with resulting orphans.

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  18. The final report is on the NTSB database. Essentially overweight at T/O, CG a bit too far aft, and was running out of fuel. While the left engine got a bit more fuel and continued to run, the right engine did not. Pilot failed to feather the right prop and raise the flaps.
    Living here in Kerrville, where he crashed is almost the best place before passing over populated areas which may have led to a bigger disaster.
    RIP

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