Sunday, January 19, 2020

Fuel Starvation: Beech F33A Bonanza, N4548S; accident occurred November 15, 2014 in Clinton, Connecticut

Front View of Main Wreckage 

Left Side View of Main Wreckage 

Rear View of Main Wreckage

Right Side View of Main Wreckage


Cowl Flaps 

Landing Gear 

Fuel Strainer 

Interior of Fuel Strainer

Fuel Strainer Screen 

Fuel Recovered from Right Wing Tank 

Fuel Recovered from Right Wing Tank 

Fuel Selector 

Throttle, Aux Pump, Propeller, and Mixture Controls 

Magneto Switch 

Engine in Test Cell 

Engine Running in Test Cell

Test Club Propeller RPM and Temperature (Full Throttle) 

Fuel Flow and Fuel Nozzle Pressure (Full Throttle) 

Fuel Pump Pressure (Full Throttle) 

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Windsor Locks, Connecticut
Textron Aviation; Wichita, Kansas
Continental Motors Inc; Mobile, Alabama
Hartzell Propeller; Piqua, Ohio

Aviation Accident Factual Report - National Transportation Safety Board:

Investigation Docket - National Transportation Safety Board:

Location: Clinton, CT
Accident Number: ERA15LA053
Date & Time: 11/15/2014, 1606 EST
Registration: N4548S
Aircraft: BEECH F33A
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

On November 15, 2014, about 1606 eastern standard time, a Beech F33A, N4548S, was substantially damaged when it impacted trees during a forced landing, after a loss of power during cruise near Clinton, Connecticut. The pilot received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91, which departed Groton-New London Airport (GON), Groton, Connecticut, destined for Orange County Airport (MGJ), Montgomery, New York.

According to the pilot, earlier in the day she had flown the airplane from MGJ to GON. She had approximately 20 gallons of fuel in each wing tank prior to departure. She did not refuel at GON.

At approximately 1555, she departed on her return flight to MGJ. After takeoff she made a left turn and established herself on course. She then climbed to 4,500 feet above mean sea level and trimmed for cruise flight, set 2,300 revolutions per minute (rpm), manifold pressure to 23 inches of mercury, and fuel flow to 13 gallons per hour.

Sometime later, air traffic control (ATC) pointed out traffic to the pilot however, the sun was directly ahead of her, and very bright, making it difficult for her to see. She then advised ATC that she was looking for traffic, and shortly afterwards, she heard "a loud explosive bang - like a gunshot." She immediately checked her instruments. The rpm had risen to "over 2,500 rpm – over redline." She then reduced the propeller control back with no effect. The airplane started to "shudder – physically shaking me." The rpm on her tachometer had now dropped to 2,000. Her airspeed had also dropped off and she began to lose altitude. She then checked her propeller setting and aggressively advanced the propeller, but there was no increase in rpm.

She contacted ATC and told them she had engine problems and declared an emergency. ATC advised her to land at Chester Airport (SNC), Chester, Connecticut, which was the nearest airport. She then requested vectors to SNC. They advised her to turn to a heading of 180° which she did. She advised ATC that she did not see the airport, nor did she see any other clearing or road. All she saw were trees, and she continued to lose altitude. She flew the airplane straight and level, as best she could, trying to maintain the airplane's best glide speed. She called ATC again requesting the location of the airport. They advised her that it was about 2 miles at her 12 o'clock position. However, she still could not see it. She realized at this point that she was not going to find the airport or any other open area before she hit the trees.

She continued to fly the airplane straight and level and decided not to put the landing gear down as she was aiming to land the airplane on top of the trees, hoping they would cushion the airplane as it descended to the ground. She reached down to shut the fuel selector off because she was afraid there might be a fire once she crashed. She knew there was still plenty of fuel on board. However, since she did it as she was approaching the treetops, she could not look at the fuel selector handle to check its setting. She knew she turned the handle, but she was not sure if she had fully turned it to the left to the "OFF" position from the right tank before the airplane then collided with the trees. 

Pilot Information

Certificate: Commercial; Private
Age: 62, Female
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 08/25/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 12/27/2013
Flight Time:  1549 hours (Total, all aircraft), 827 hours (Total, this make and model), 1018 hours (Pilot In Command, all aircraft), 13 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)

The pilot held a Federal Aviation Administration (FAA) commercial pilot certificate with ratings for airplane single-engine land, and instrument airplane. Her most recent FAA second-class medical certificate was issued on August 25, 2014. She reported that she had accrued approximately 1,549 total flight hours, 827 of which, were in the accident airplane make and model.

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N4548S
Model/Series: F33A
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: CE-601
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 02/22/2014, Annual
Certified Max Gross Wt.: 3400 lbs
Time Since Last Inspection: 39 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3016.02 Hours at time of accident
Engine Manufacturer: Continental
ELT: C91 installed, not activated
Engine Model/Series: IO-550-B
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 

On November 4, 1999, in accordance with FAA Supplemental Type Certificate SA2200SW, the installed Continental IO-550-BA engine was replaced with a 300 horsepower, air cooled, 6-cylinder, horizontally opposed, Continental IO-550-B equipped with a Hartzell 3-bladed, variable pitch, constant speed propeller.

Its most recent annual inspection was completed on February 22, 2014. At the time of the accident, the airplane had accrued 3,016.02 total hours of operation, and the engine had accrued 866.72 total hours of operation since major overhaul.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: SNC, 416 ft msl
Distance from Accident Site: 4 Nautical Miles
Observation Time: 1555 EST
Direction from Accident Site: 8°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 320°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.27 inches Hg
Temperature/Dew Point: 3°C / -11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Groton, CT (GON)
Type of Flight Plan Filed: None
Destination: Montgomery, NY (MGJ)
Type of Clearance: VFR Flight Following
Departure Time: 1555 EST
Type of Airspace: Class E 

The recorded weather at Chester Airport (SNC), Chester, Connecticut, located 3.7 nautical miles north of the accident site, at 1555, included: winds 320° at 7 knots, 10 miles visibility, sky clear, temperature 3° C, dew point -11° C, and an altimeter setting of 30.27 inches of mercury.

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude: 41.319167, -72.528333 

Examination of the accident site and wreckage revealed that the airplane came to rest inverted, in a nose and left wing down position, wedged between trees, about 6 feet above ground level.

Airplane Examination

Examination of the airplane revealed that the wings, fuselage, engine, and empennage were impact damaged. Control continuity was established to the ailerons, elevators, and rudder. The wing flaps were retracted, and the flap selector switch was in the up (retracted) position. The elevator trim position indicator displayed about a 6° nose up trim position.

The landing gear was retracted, the landing gear selector was in the up (retracted) position, and the emergency gear extension handle was stowed. The magnetos switch was in the left magneto position. The battery master and alternator switches were on, the auxiliary instrument air switch was in the on position, the pitot heat switch was in the off position. The strobes, electronic flight instrumentation, and navigation lights switches, were in the on position.

The throttle control was in the full open position, the mixture control was in the full rich position, and the propeller was in the high rpm position. The auxiliary fuel pump was off, and the cowl flaps were open.

First responders did not report an evidence of a fuel spill though both the left, and right, wing tip tanks, and the left, and right, wing fuel bladders were breached. The tip tanks were totally devoid of fuel, but fuel was discovered to be trapped in the undamaged portion of each of the wing tank's fuel bladders. About 17 gallons of fuel was recovered from the right-wing tank. Less than 1 gallon of fuel was recovered from the left-wing tank. The fuel selector was in the "LEFT TANK" position. The fuel strainer was clean, free of debris, and devoid of fuel. No fuel was recovered from the fuel supply line to the engine driven fuel pump.

Propeller Examination

The propeller had remained attached to the engine; and the blades had remained secured in the hub.

On January 27, 2015, the propeller was examined at Hartzell Propeller Incorporated.

During the examination it was discovered that the spinner dome was crushed on one side and was still attached to the spinner bulkhead, which was intact, but was bent around the edges. The engine to the propeller mounting was intact and unremarkable.

One propeller blade was unremarkable, the tip of the other two propeller blades were bent aft. None of the blades displayed leading edge impact damage.

The cylinder, piston, pitch change rod, fork, spring, and low and high pitch stops, were all intact and unremarkable. The hub assembly was also intact and unremarkable, and the preload plates displayed normal wear.

The blade bearings were all intact and unremarkable. Two of the pitch change knobs were fractured off. Metallurgical examination indicated that they had failed by ductile overload under shear or tearing stresses, with no indication of fatigue cracking.

Engine Examination

On March 24, 2015 the engine was examined at Continental Motors Incorporated (CMI).

Examination revealed that the engine had sustained impact damage during the accident sequence, and all the fuel lines going to the fuel metering assembly had broken free from the assembly. The fuel inlet fitting going to the engine driven fuel pump had broken free from the fuel pump. The ignition harness displayed tearing in several locations; however, none of the ignition lines were severed. All four engine mounts were broken consistent with impact damage. The right-side exhaust displayed bending deformation consistent with impact damage and the intake balance tube was crushed.

The fuel pump was disassembled, and the internal components were inspected. There were no anomalies noted with the engine driven fuel pump. The cylinders were examined using a lighted borescope and the pistons, cylinder bore, and valve heads displayed normal operating and combustion signatures.

The magneto-to-engine timing was then checked and compared to the specified magneto to engine timing of 22° before top dead center (BTDC) with the following results:

Left Magneto: 25° BTDC
Right Magneto: 23° BTDC

A cylinder leakage test was then performed in accordance with the latest revision of CMI Service Bulletin SB03-3 with the engine at room temperature with the following results (master orifice reading – 39 PSI):

Cylinder No.1 - 26/80 PSI
Cylinder No.3 - 6/80 PSI
Cylinder No.5 - 10/80 PSI

Cylinder No.2 - 36/80 PSI
Cylinder No.4 - 39/80 PSI
Cylinder No.6 - 50/80 PSI

The leakage source for all 6 cylinders were the exhaust valves and piston rings.

Engine Run

After the examination, the engine was prepared for an engine run by removing the propeller governor, along with various airframe related hoses. Due to damage that the engine sustained, the following parts were installed in preparation for the engine run:

Engine driven fuel pump (the fuel pump housing was damaged while attempting to remove remains of the fuel inlet fitting)

The right-side exhaust system

All four engine mounts

All three AN fittings going into the fuel metering assembly

The No.6 top spark plug

The engine was not disassembled prior to the engine run. The crankshaft end-play measured 0.01" and the run-out was 0.002". Deflection was measured at .003."

The engine was then prepared for operation by installation of thermocouples, pressure lines and test pads for monitoring purposes. The engine was then moved to a test cell, mounted for operation, and fitted with a club propeller.

During the engine run, the engine started on the first attempt without hesitation. The engine RPM was brought to 1,000 rpm to warm up the engine to normal operating temperatures. The engine was then run at 1,200 rpm for five minutes to stabilize. The engine throttle was then advanced to 1,600 rpm and held there for five minutes to stabilize. The engine throttle was then advanced to 2,100 rpm and held there for five minutes to stabilize. The engine throttle was then advanced to 2,450 rpm and held there for five minutes to stabilize. The engine throttle was then advanced to the full open position and held there for five minutes to stabilize.

The engine throttle was then rapidly advanced from idle to full throttle six times, where it performed normally without any hesitation, stumbling, or interruption in power. Throughout the engine run, the engine operated normally and there were no anomalies noted.

Flight Recorders

The airplane was equipped with a JP Instruments, JPI FS-450 Electronic Fuel-Flow Indicator, and a Garmin International, GPSMAP 496.

JPI FS-450 Device

The JPI FS-450 electronic fuel-flow indicator in the airplane was a cockpit panel mounted computerized display device that presented information to the pilot about the fuel usage of the airplane. The indicator had two modes, one mode displayed the total fuel used and the remaining fuel on-board the airplane. An accurate fuel remaining value relied on the pilot to initialize the device when refueling. The second mode displayed, in real-time, the engine fuel-flow. In addition to the display, the JPI unit could provide fuel information to the airplane's navigational systems to allow them to calculate and display fuel at various waypoints along the programmed flight track. The JPI unit could retain in its memory, fuel used and fuel remaining values after electrical power was removed.

Data extraction from the unit's memory indicated that the pilot had not initialized the device in quite some time, as the Fuel Used and Remaining values were recorded as:

Fuel Used: 285.3 Gallons
Remaining: 0 Gallons

GPSMAP 496 Device

Data extracted from the unit included 37 flights from May 11, 2014 through November 15, 2014.

The duration of the first flight on the day of the accident from MGJ to GON was recorded to be about 1 hour and 3 minutes long, starting at 10:20:03 and ending at 11:23:07. The accident flight was recorded as departing from GON about 4 hours and 18 minutes later. The airplane was then airborne for about 26 minutes with the recorded data starting at 15:41:27 and ending at 16:07:52.

Review of the data indicated that after the pilot reported the engine problem, the airplane's flight path also continued past SNC and passed within 2,373 ft from the end of runway 35, before the airplane turned to the southeast towards the area where the airplane came to rest after striking trees during the emergency landing.

Tests And Research

Fueling Information

A review of fueling information from MGJ airport revealed that the airplane was not fueled from either the full-service or self-service fuel pumps at the airport prior to departure to GON. Records indicated that the last recorded fuel transaction at MGJ for the airplane was on July 19, 2014.

Fuel System

The fuel cell installation consisted of a 40-gallon capacity fuel cell (37- gallon usable) and filler cap in each wing leading edge. The filler neck for each fuel cell contained a visual measuring tab to permit partial filling of the fuel cell. Filling the fuel cell until the fuel touched the bottom of the tab indicated 27 gallons of usable fuel, and filling to the slot in the tab indicated 32 gallons of usable fuel.

The airplane was also equipped with a 15-gallon fiberglass tip tank on each wing. Fuel in the tip tanks could be transferred to each respective main tank in cruise flight by transfer pumps mounted in the wheel wells. Sufficient fuel from the main tanks was required to be used from the main tanks prior to activating the transfer pumps to prevent fuel from being vented overboard.

Fuel System Guidance

According to the Beechcraft Bonanza F33A Pilot's Operating Handbook and FAA Approved Airplane Flight Manual (POH/AFM), The pilot was required to preplan all aspects of their flight including a proper weather briefing and adequate fuel reserves and to assure that they had enough fuel for takeoff, plus the trip, and an adequate reserve.

The POH/AFM also instructed that the pilot should preplan the fuel and fuel tank management before the actual flight, to utilize auxiliary tanks only in level cruise flight, to take off and land only on the fullest main tank, and to never use auxiliary tanks for takeoff or landing.

It also instructed to not take off with less than minimum recommended fuel plus adequate reserves, to not run the tank dry before switching tanks, to takeoff on the main tank that is more nearly full, and that when operating fuel selector, and to feel for the detent position. It also instructed to not take off when the fuel quantity gauges indicate in the yellow band, or with less than 13 gallons in each main tank.

Engine Failure and Engine Discrepancy Guidance

According to the POH/AFM, in the event of an engine failure after liftoff and in flight, if sufficient altitude was available for maneuvering, to accomplish the following emergency procedures:

Fuel Selector Valve – SELECT OTHER TANK (Check to feel detent)
Auxiliary Fuel Pump – ON
Mixture – FULL RICH, then LEAN as required
Magnetos – CHECK LEFT and RIGHT, then BOTH

The POH/AFM also contained a "NOTE" that stated:

"The most probable cause of engine failure would be loss of fuel flow or improper functioning of the ignition system."

If no engine restart occurred, the POH/AFM directed the pilot to:

Select most favorable landing site.
The use of landing gear is dependent on the terrain where landing must be made.

The POH/AFM also under "ENGINE DISCREPANCY CHECKS," instructs the pilot in the event of a rough running engine to accomplish the following actions:

Mixture – FULL RICH, then LEAN as required
Magneto/Start Switch – CHECK LEFT and RIGHT, then BOTH

Also, if a loss of engine power occurs to:

Fuel Flow Gage – CHECK

Or if fuel flow is abnormally low to:

Mixture – FULL RICH
Auxiliary Fuel Pump – ON (Lean as required)
Auxiliary Fuel Pump – OFF if performance does not improve in a few moments

Fuel Quantity Indicator – CHECK for fuel supply in tank being used

If tank being used is empty:

Fuel Tank Selector Valve – SELECT OTHER FUEL TANK (feel for detent)

Maximum Glide Configuration Guidance

Further review of the POH/AFM also revealed that it contained guidance for maximum glide configuration to increase glide distance in the event of a loss of engine power. It instructed the pilot to accomplish the following:

Landing Gear – UP
Flaps – UP
Cowl Flaps – CLOSED
Propeller – PULL for LOW RPM
Airspeed – 105 kts/121mph

Use of the procedure would increase the glide distance about 1.7 nautical miles (2 statute miles) per 1,000' of altitude above the terrain.

Emergency Landing Guidance

When landing without power, the POH/AFM, instructed the pilot on final approach to accomplish the following actions:

Airspeed – 83 kts/96 mph
Fuel Selector Valve - OFF
Mixture – IDLE CUT - OFF
Magneto/Start Switch - OFF
Battery and Alternator Switches - OFF

Additional Information

According to the Airplane Flying Handbook (FAA-H-8083-3B), there are several factors that may interfere with a pilot's ability to act promptly and properly when faced with an emergency. Some of these factors are listed below:

Reluctance to accept the emergency situation—a pilot who allows the mind to become paralyzed at the thought that the airplane will be on the ground in a very short time, regardless of the pilot's actions or hopes, is severely handicapped in the handling of the emergency. An unconscious desire to delay the dreaded moment may lead to such errors as: failure to lower the nose to maintain flying speed, delay in the selection of the most suitable landing area within reach, and indecision in general. Desperate attempts to correct whatever went wrong at the expense of airplane control fall into the same category.

Undue concern about getting hurt—fear is a vital part of the self-preservation mechanism. However, when fear leads to panic, we invite that which we want most to avoid. The survival records favor pilots who maintain their composure and know how to apply the general concepts and procedures that have been developed through the years. The success of an emergency landing is as much a matter of the mind as of skills.

The Airplane Flying Handbook also advised that, the key to successful management of an emergency situation, and/ or preventing a non-normal situation from progressing into a true emergency, is a thorough familiarity with, and adherence to, the procedures developed by the airplane manufacturer and contained in the POH/AFM.


  1. Looks like the RH tank lasted about as long as it should have.

    Glad she is ok.

    1. It's amazing how well these engines run when they have fuel.