Sunday, July 11, 2021

Loss of Engine Power (Total): Beechcraft A36 Bonanza, N1809S; fatal accident occurred July 05, 2019 near Greater Kankakee Airport (KIKK) , Illinois

Dorothy Carlene Stockard
March 26, 1935 - July 06, 2019


















Aviation Accident Final Report - National Transportation Safety Board 

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Springfield, Illinois
Textron Aviation; Wichita, Kansas
Continental Aerospace Technologies; Mobile, Alabama

Investigation Docket - National Transportation Safety Board:


Location: Chebanse, Illinois 
Accident Number: CEN19FA210
Date & Time: July 5, 2019, 13:41 Local 
Registration: N1809S
Aircraft: Beech A36 
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total) 
Injuries: 1 Fatal, 1 Serious, 1 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot reported that, during a cross-country flight, while in cruise altitude at 3,000 ft mean sea level, the engine lost power. He subsequently performed a forced landing to a muddy wheat field. Examination at the site revealed that the left and right main fuel tanks were intact; the left tank was empty and the right tank contained about 25 gallons. The wing tip tanks were breached during the accident, but burns in the field were indicative of fuel being in the wing tip tanks at the time they were breached. The fuel selector was found in the left tank position.

Further examination revealed that the fuel line from the fuel selector to the engine-driven fuel pump contained no fuel. A test run of the engine revealed no anomalies. Given the absence of fuel in the left tank, the position of the fuel selector at the accident site, and the engine's nominal performance during a postaccident test run, it is likely that the engine consumed all of the available fuel in the left fuel tank, which resulted in fuel starvation and a subsequent total loss of engine power.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A total loss of engine power due to fuel starvation.

Findings

Aircraft Fuel - Fluid management
Personnel issues Use of equip/system - Pilot

Factual Information

History of Flight

Enroute-cruise Loss of engine power (total) (Defining event)
Emergency descent Off-field or emergency landing

On July 5, 2019, at 1341 central daylight time, a Beech A36 airplane, N1809S, was substantially damaged when it was involved in an accident near Chebanse, Illinois. The pilot sustained serious injuries, one passenger was fatally injured, and one passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

Data from the ForeFlight application revealed that the airplane departed Effingham Memorial Airport (1H2), Effingham, Illinois, at 0901 and arrived at Smyrna Airport (MQY), Smyrna, Tennessee, at 1034. After picking up a passenger, the pilot departed MQY at 1134 for Bolingbrook's Clow International Airport (1C5), Bolingbrook, Illinois; climbing to a cruise altitude of 3,000 ft msl.

The pilot reported that the takeoff and initial portion of the accident flight were routine, and the engine was running "fine." While in cruise, he heard a "big boom," and the engine lost power. He noted that the engine seemed to be running but was not producing any power; the engine indications were normal. The pilot performed a forced landing to a wheat field. Upon touchdown, the wheels "stuck" due to the muddy conditions and the airplane came to an abrupt stop.

The pilot recalled checking the fuel quantity gauges shortly before the loss of power; he stated that one main tank was over 1/2 full and the other was about 3/4 full. He had not activated the wing tip fuel tank transfer pumps because there was still over 1/2 fuel remaining in the main tanks. 

Pilot Information

Certificate: Commercial; Flight instructor 
Age: 70, Male
Airplane Rating(s): Single-engine land; Multi-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): Airplane single-engine; Instrument airplane
Toxicology Performed: Yes
Medical Certification: Class 3 Waiver time limited special 
Last FAA Medical Exam: August 6, 2018
Occupational Pilot: No Last Flight Review or Equivalent: September 2, 2018
Flight Time: 2823 hours (Total, all aircraft), 334 hours (Total, this make and model), 2635 hours (Pilot In Command, all aircraft), 62 hours (Last 90 days, all aircraft), 24 hours (Last 30 days, all aircraft), 4 hours (Last 24 hours, all aircraft)

The pilot satisfactorily completed the flight instructor practical test on September 2, 2018, which met the requirement for a flight review in accordance with 14 CFR Part 61.56 (d) (2).

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N1809S
Model/Series: A36 
Aircraft Category: Airplane
Year of Manufacture: 1981
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-1875
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: July 2, 2019 Annual 
Certified Max Gross Wt.: 3780 lbs
Time Since Last Inspection: 5 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 4135 Hrs at time of accident
Engine Manufacturer: Continental Motors
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: IO-520-BB(17)
Registered Owner: 
Rated Power: 285 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

The pilot stated that the airplane's main and wing tip fuel tanks were filled to capacity before departing 1H2. The airplane was not fueled at MQY. He stated that he normally used a cruise power setting of 2,300 rpm and 23" manifold pressure. 

The airplane was equipped with two main tanks that held a total of 80 gallons, of which 74 gallons were useable. The two wing tip fuel tanks had a total capacity of 30 gallons, of which all 30 gallons were useable. The flight manual supplement noted that fuel was transferred from each wing tip tank to the respective main tank by an electric fuel transfer pump.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: IKK,630 ft msl 
Distance from Accident Site: 5 Nautical Miles
Observation Time: 13:55 Local 
Direction from Accident Site: 354°
Lowest Cloud Condition: Scattered / 3900 ft AGL
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 7 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 300° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 32°C / 22°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Smyrna, TN (MQY) 
Type of Flight Plan Filed: None
Destination: Bolingbrook, IL (1C5)
Type of Clearance: None
Departure Time: 11:35 Local 
Type of Airspace: Class G

Winds aloft along the route of flight were from the west-southwest about 8 knots.

Airport Information

Airport: Greater Kankakee IKK
Runway Surface Type:
Airport Elevation: 630 ft msl
Runway Surface Condition: Vegetation
Runway Used: 
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced landing

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal, 1 Minor
Aircraft Fire: On-ground
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious, 1 Minor
Latitude, Longitude: 40.991943,-87.835556

The airplane came to rest in a muddy wheat field. The fuselage and both wings were damaged during the forced landing. Both wing tip fuel tanks were compromised. The wheat field was scorched in an area behind the left wing tip and below and behind the right wing tip. Both main wing fuel tanks appeared intact and both fuel caps were securely installed. At the time of the examination, the left main fuel tank was empty, and the right main fuel tank contained about 25 gallons of fuel. The fuel selector was positioned to the left main fuel tank. No fuel was observed in the fuel line from the fuel selector to the engine-driven fuel pump. Minimal fuel was observed in the fuel line from the fuel manifold to the mixture control. No residual fuel was expelled from the engine-driven fuel pump when it was operated manually. The auxiliary fuel pump switch was in the off position. The switch for the left wing tip fuel tank transfer pump was off, and the switch for the right wing tip tank transfer pump was on.

An airframe examination did not reveal any anomalies consistent with a preimpact failure or malfunction. An engine test run was conducted, during which the engine performed normally and responded to all throttle inputs without hesitation. During the test run, fuel leaks were observed at the throttle body/mixture control and the engine-driven fuel pump. The o-rings in both components were removed and found to be hardened, worn, and brittle. The o-rings were replaced, and the components performed normally during the test run. The engine test run revealed no anomalies consistent with an inability to produce rated power.

The airplane was equipped with a Shadin Microflo-L fuel management system. The operating manual noted that the Microflo-L is a fuel flow measuring system and not a quantity-sensing system. Positive determination of the usable fuel on-board and accurate entry of that information into the unit is required; however, the pilot reported that he did not recall initializing the system before either flight on the day of the accident. The airplane was also equipped with an Insight G1 graphic engine monitor. However, the unit did not have data logging capability.





22 comments:

  1. Toxicology performed but no results published?

    ReplyDelete
  2. More info here; https://abc7chicago.com/plane-crash-beechcraft-a36-small-airplanes-iroquois-county-illinois/5381970/

    ReplyDelete
  3. 'The engine failed and he is a hero' Hero: Pilot treated at Loyola burn unit, expected to be OK.
    Link/Page Citation

    Byline: Justin Kmitch jkmitch@dailyherald.com

    Wrenne Jakubiak says a federal investigation into the private plane crash Friday that killed her sister and injured both her and her husband has limited what she can share about what happened, but there is one thing she wants everyone to know.

    "My husband, Ray Jakubiak, is a hero," she said Monday, her voice cracking. "The engine failed and he is a hero."

    Investigators say Raymond Jakubiak, 70, of the 900 block of South Charles Avenue in Naperville, was flying his 1981 Beech A36 single-engine aircraft from Nashville to the Chicago area when it began experiencing engine problems.

    The six-seater, that records show he bought in 2013, caught fire after Jakubiak made an emergency landing in a wheat field near Chebanse, about 10 miles south of Kankakee.

    Iroquois County sheriff's officials said Monday they are assisting in the investigation, but that their reports are not complete.

    Wrenne Jakubiak's sister, Dorothy Stockard, 84, of Hermitage, Tennessee, died as a result of injuries suffered in the crash.

    Wrenne Jakubiak, 70, was treated for burns and released from Loyola University Medical Center in Maywood the same day. She said Raymond was still in Loyola's burn unit as of Monday morning, but he is "expected to be OK."

    The investigation will be conducted by the National Transportation Safety Board and a report will be completed in about two weeks, according to agency spokesman Eric Weiss.

    ReplyDelete
    Replies
    1. So does his wife still believe he's a 'hero' now that the final report finds the cause of the crash to be his leaving the fuel tank selector valve in the left position ? Condolences to her on the loss of her sister.

      Delete
  4. CFI with 2,800 hours. Not much you can say about this one.

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  5. One could say this, and preach it to every student that pursues a pilots license. …. On every flight, without exception, know exactly how many gallons of fuel you have in each tank. Know the fuel system of the airplane you are flying, don’t “guess” that the fuel selector is positioned correctly. Use a timer and a written, visual notation of time on tank and fuel used.
    My Bonanza has 6 fuel tanks, two mains of 25 gallons each .. two aux tanks of 10 each plus two tip tanks of 20 each. Excess fuel flows into the left tank. Managing fuel is as important as navigating the airplane, no matter the distance.
    This crash emphasizes my point.

    ReplyDelete
    Replies
    1. Jeezus Christ....way too many tanks to manage on Bonanzas. I'm so used to the C172's gravity feed(no pump!) and "both" selector you never have to worry about mismanagement of fuel's whereabouts. And burns constant 8-10G/hr. With that said, even simple Piper Cherokee's left/right selector gives me concerns that one day I might forget to switch to the other side and cause starvation. *I am a CFI with more than 20 years just flying C172.

      Delete
  6. One could also say that these 70-year-old guys who still think they have the 'Right Stuff' are deluding themselves.

    ReplyDelete
    Replies
    1. age had nothing to do with it. try another argument, junior.

      Delete
    2. I concur with you both:
      Age has nothing to do. But, maybe these 70 y/o that think to pilot a plane is a matter have the right stuff, instead of being a check lists and procedures following guys, like ... ATPs.

      Delete
    3. Age could be a contributing factor in this case. You ever heard of dementia?
      He could have "forgotten" to switch tanks.
      Quote from above pilot info: Medical Certification: Class 3 Waiver time limited special
      Last FAA Medical Exam: August 6, 2018
      Wonder what the time limit was? Even so, No medical in 3 years at age 70?
      Odd that the FAA database shows NO medical info. To keep a commercial certificate valid you must have a second class physical once a year.
      Personal Information

      RAYMOND PATRICK JAKUBIAK
      927 S CHARLES AVE
      NAPERVILLE IL 60540-7610
      County: DUPAGE
      Country: USA
      Medical Information:
      No Medical Information Available
      Certificates
      COMMERCIAL PILOT
      FLIGHT INSTRUCTOR
      Certificates Description
      Certificate: COMMERCIAL PILOT
      Date of Issue: 6/7/2010
      Ratings:
      COMMERCIAL PILOT
      AIRPLANE SINGLE ENGINE LAND
      AIRPLANE MULTIENGINE LAND
      INSTRUMENT AIRPLANE

      Limits:
      ENGLISH PROFICIENT

      Delete
    4. Cybercraig, I'm glad you seem to be the only one that "gets it" Seems like you have had a great life. Good fortune to you in the future! And yes, I can tell your personality and attitude by your simple comment.
      JW

      Delete
  7. ok? this did not have to happen(my opinion) If you got to put it down in a wet wheat field...how about "Gear up" also my opinion....very unfortunate for elderly passenger(sister in law)

    ReplyDelete
    Replies
    1. I thought the same thing.

      Delete
    2. Agree. Gear up and probably no fatality. 2nd mistake by the pilot.

      Delete
  8. if you can afford ur own high performance single engine piston, you can order "top off" at each FBO along the way!

    ReplyDelete
    Replies
    1. True, but if your last leg was a 5 hr cross country and you didn't switch tanks along the way, guess what....You crash land in a muddy wheat field.
      So just saying, just because you "topped off fuel" doesn't mean you'll not run out of fuel if you forget to switch tanks. Not an accurate analogy.

      Delete
  9. Agreed, flight management checklists and fuel management with a reserve is a must, which requires use and PIC discipline; with age we lose that discipline, which I can attest to.

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  10. Should be charged with manslaughter. No excuses to be that incapable. Manage fuel=no accident. Leave gear up=walk away. Just that simple.

    ReplyDelete
  11. "To keep a commercial certificate valid you must have a second class physical once a year."

    Only if you want to exercise commercial privileges. I can "keep" my commercial certificate, and fly, with zero medical certificates in the past 10 years. It's called BasicMed.

    ReplyDelete