Wednesday, August 24, 2022

Fuel Starvation: Beech 35 Bonanza, N3394V; fatal accident occurred March 06, 2021 near Palestine Municipal Airport (KPSN), Anderson County, Texas

LaRue F. Allen
1956 - 2021
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Aviation Accident Final Report - National Transportation Safety Board
 

Investigator In Charge (IIC): Hodges, Michael

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Irving, Texas
Textron Aircraft; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:


Location: Palestine, Texas
Accident Number: CEN21LA151
Date and Time: March 6, 2021, 12:17 Local
Registration: N3394V
Aircraft: Beech 35 
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The airplane was recently purchased by the copilot. The day before the accident, a mechanic performed a pre-buy/annual inspection on the airplane, which had not been inspected in over 8 years, with no issues annotated in the maintenance records. On the day of the accident, the pilot and copilot departed for the cross-country flight of about 200 nautical miles to the copilot’s home airport. The copilot reported a total of 54 gallons of fuel between the three fuel tanks (17 gallons each in the left and right tanks and 20 gallons in the auxiliary tank) at departure. He also reported that the generator was inoperative, and the flight was made with the retractable landing gear in the extended position. About 43 minutes into the flight, the fuel in the left-wing fuel tank was “depleted,” and the crew switched to the right-wing fuel tank with no issues. The pilot suggested they switch to the auxiliary fuel tank, and when the copilot switched to the auxiliary fuel tank, a total loss of engine power occurred.

The copilot switched the fuel selector to its “opposite position” and then switched it back to the right fuel tank but power was not restored. The crew attempted to restart the engine several times with no success, and the pilot transferred the flight controls to the copilot for a forced landing. The copilot maneuvered the airplane through a canopy of trees, and the airplane then impacted the ground resulting in substantial damage to both wings and the fuselage.

During post-accident examination, the required fuel selector placard depicting the four selectable positions (RIGHT TANK, LEFT TANK, AUXILIARY TANK, and OFF) was not observed in the wreckage. The fuel selector was found with the handle between the OFF and LEFT TANK positions; in this position, fuel would not pass through the selector. Detents that should have been felt at the four selectable positions were not noted as the handle was rotated through the fuel tank positions. The mechanic reported there were no issues noted with the airplane during the annual inspection performed one day before the accident and the mechanic classified the airplane as “complete.”

None of the three fuel tanks contained observable fuel levels on scene. There was no evidence of fuel spillage, smell, or vegetation blighting at the accident site. The right-wing and auxiliary tanks were not breached. The left-wing bladder was punctured by a fracture in the inboard wing rib that likely occurred during impact.

Although the copilot reported that the fuel selector placard was installed, review of his cell phone records indicated that during the flight, he sent a text message to the previous airplane owner asking what position on the fuel selector was for the auxiliary fuel tank. Therefore, it is likely the fuel selector placard was not installed in the airplane. The text message also indicates the flight crew lacked an understanding of how to properly operate the fuel selector.

According to the copilot, there should have been fuel available when the engine power loss occurred. Based on the examination of the fuel system, the reason for the lack of fuel at the accident site could not be determined. Given that the fuel selector was found in a position where fuel would not pass through it, that the fuel selector placard was not installed, and that the flight crew lacked adequate knowledge of fuel selector operation, it is likely the flight crew incorrectly placed the fuel selector between the fuel tank detents, which resulted in a loss of engine power.

The airframe manufacturer issued a service bulletin 23 years before the accident about adding an updated placard to the fuel selector due to reports of incidents and accidents involving engine failure due to pilots incorrectly positioning the fuel selector between fuel tank detents. The service bulletin stated that a no-flow condition exists between the fuel tank detents. The airplane maintenance records did not show that this service bulletin was complied with, nor was it required to be complied with.

Based on autopsy findings, the pilot had severe atherosclerotic disease in his left anterior descending coronary artery. Although this condition placed him at an increased risk for a sudden incapacitating event, including a heart attack, stroke, or arrhythmia that could cause acute symptoms without leaving evidence on autopsy, his autopsy did not show any evidence of an acute event. Additionally, the surviving copilot did not report that the pilot had experienced an impairing or incapacitating event, and they were both making efforts to correct the power loss and land the airplane. The autopsy also noted evidence of medical intervention on the fatally injured pilot. Atropine, a drug used for resuscitation that was detected on toxicology testing, was likely administered in life-saving efforts. Thus, the pilot’s cardiovascular condition would not have contributed to this accident, and the detection of atropine was from post-accident treatment.

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 the flight crew incorrectly placing the fuel selector between fuel tank detents, which resulted in fuel starvation. Contributing to the accident was the lack of a placard on the fuel selector, the lack of obvious fuel tank detents in the fuel selector, and the flight crew’s lack of understanding of proper fuel selector operation.

Findings

Aircraft (general) - Failure
Aircraft Fuel selector/shutoff valve - Malfunction
Aircraft Fuel selector/shutoff valve - Incorrect use/operation
Aircraft Fuel selector/shutoff valve - Not serviced/maintained
Personnel issues Use of equip/system - Flight crew

Factual Information

History of Flight

Enroute Fuel starvation (Defining event)
Enroute Loss of engine power (total)
Enroute Attempted remediation/recovery
Enroute Off-field or emergency landing
Landing Collision during takeoff/land

On March 6, 2021, about 1217 central standard time, a Beech 35 airplane, N3394V, sustained substantial damage when it was involved in an accident near Palestine, Texas. The private pilot sustained fatal injuries, and the private copilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The airplane was recently purchased by the copilot. The pilot traveled from out of state to help the copilot fly the airplane from Chambers County Airport (T00), Anahuac, Texas, to the copilot’s hangar at Airpark East Airport (1F7), Dallas, Texas, a distance of about 200 nautical miles. The day before the accident, a pre-buy/annual inspection was performed by a mechanic on the airplane with no issues annotated in the maintenance records. The copilot reported that the generator was not functioning, and the placard on the fuel selector was present. The airplane was topped off with 100 low lead fuel. According to the copilot, the left fuel tank contained 17 gallons, the right fuel tank contained 17 gallons, and the auxiliary fuel tank in the baggage compartment contained 20 gallons for a total of 54 gallons.

On the day of the accident, the pilot and copilot performed traffic pattern maneuvers, and no issues were noted with the airplane except for the inoperative generator. They then departed for 1F7. The flight was conducted with the retractable landing gear extended. During the flight, both pilots flew the airplane. The copilot reported that the fuel gauges “worked normally,” that the carburetor heat was not on during the flight, and that they were running the engine “rich” during the flight “in order to keep the engine cylinders cool.” About 43 minutes into the flight, the fuel in the left fuel tank was “depleted,” and the crew switched to the right fuel tank with no issues. The pilot was concerned about “maximizing” the airplane’s fuel capacity and suggested using the auxiliary fuel tank. The copilot switched to the auxiliary fuel tank, and a total loss of engine power occurred.

The copilot then switched the fuel selector to its “opposite position,” but the engine did not regain power. The copilot switched back to the right fuel tank with no change noted. The crew then initiated the emergency restart procedure, and they used the hand fuel pump as they attempted to restart the engine five or six times with no success.

The pilot transferred the flight controls to the copilot for the forced landing. The copilot maneuvered the airplane through the canopy of several trees, and the airplane came to rest upright on a grass field on a ranch. The copilot egressed from the airplane and contacted first responders with a cellular phone.

Examination of the copilot’s cellular phone at the National Transportation Safety Board’s (NTSB’s) Vehicle Records Laboratory revealed that during the accident flight at 1203, the copilot sent a text message to the previous airplane owner asking what position on the fuel selector was for the auxiliary fuel tank. Starting at 1213, the co-pilot received three text messages from the mechanic describing three positions for the fuel selector.

Co-pilot Information

Certificate: Private
Age: 61,Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: Lap only
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed:
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: April 3, 2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 1300 hours (Total, all aircraft), 0.3 hours (Total, this make and model), 1998 hours (Pilot In Command, all aircraft)

Pilot Information

Certificate: Flight instructor 
Age: 65, Male
Airplane Rating(s): Single-engine land 
Seat Occupied: Right
Other Aircraft Rating(s): Glider
Restraint Used: Lap only
Instrument Rating(s): Airplane 
Second Pilot Present: Yes
Instructor Rating(s): Airplane single-engine 
Toxicology Performed: Yes
Medical Certification: Class 3 With waivers/limitations
Last FAA Medical Exam: August 7, 2013
Occupational Pilot: No 
Last Flight Review or Equivalent:
Flight Time: (Estimated) 1207 hours (Total, all aircraft)

The personal flight logs of the copilot and the pilot were not available for review during the investigation.

Aircraft and Owner/Operator Information

Aircraft Make: Beech
Registration: N3394V
Model/Series: 35 Undesignated Series
Aircraft Category: Airplane
Year of Manufacture: 1947 
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: D869
Landing Gear Type: Retractable - Tricycle 
Seats: 4
Date/Type of Last Inspection: March 5, 2021 Annual 
Certified Max Gross Wt.: 2550 lbs
Time Since Last Inspection: 1.5 Hrs 
Engines: 1 Reciprocating
Airframe Total Time: 3036.9 Hrs at time of accident
Engine Manufacturer: Continental Motors
ELT: C91 installed, activated, did not aid in locating accident
Engine Model/Series: E-185-8
Registered Owner: 
Rated Power: 205 Horsepower
Operator: On file 
Operating Certificate(s) Held: None
Operator Does Business As: None
Operator Designator Code: None

The limitations section of the Beech 35 Pilot’s Operating Handbook (POH), which contained the limitations required by regulation, discussed the airplane fuel system and stated that the standard fuel system was two 20-gallon wing fuel tanks with a total of 35 gallons of usable fuel. The optional fuel system, which was installed in the airplane, consisted of the two 20-gallon wing tanks and one 20-gallon auxiliary fuel tank installed in the baggage compartment that added 19 gallons of usable fuel to the system. The limitations section of the POH also stated, “when operating fuel selector, feel for detent position,” and it included a diagram showing the placard that was required to be installed on the fuel selector valve. The placard showed four positions for the fuel selector: right main tank at 3 o’clock, off at 6 o’clock, left tank at 9 o’clock, and auxiliary tank at 12 o’clock.

A review of the airplane’s maintenance records revealed that the most recent work performed before the pre-buy/annual inspection on the day before the accident was an annual inspection in August 2012. The mechanic reported there were no issues noted with the airplane during the annual inspection performed one day prior to the accident and the mechanic classified the airplane as “complete.” Before August 2012, annual inspections were performed in October 2010 and April 1994.

Raytheon Aircraft Company issued Service Bulletin 2760, titled “Placards and Markings – Installation of Fuel Selector Placard,” in May 1998. This document was applicable to the accident airplane and stated in part:

This Service Bulletin is being issued to add placards to the fuel selector because Raytheon Aircraft Company has received reports of incidents and accidents involving Beech piston airplanes in which engine stoppage may have been caused by incorrectly positioning the fuel selector between tank detents.

A review of the airplane’s maintenance records did not reveal any references to Service Bulletin 2760, which Raytheon Aircraft Company classified as mandatory. The Federal Aviation Administration (FAA) does not mandate compliance with service bulletins for 14 CFR Part 91 operations.

The FAA issued Airworthiness Directive (AD) 99-05-13 in April 1999, which was applicable to the accident airplane, and stated, in part:

This AD requires installing a placard on the fuel tank selector to warn of the no-flow condition that exists between the fuel tank detents. This AD is the result of reports of engine stoppage on the affected airplanes where the cause was considered to be incorrect positioning of the fuel selector. The actions specified by this AD are intended to help prevent a lack of fuel flow to the engine caused by incorrect positioning of the fuel selector, which could result in loss of engine power.

The FAA later withdrew the AD in July 2000. The maintenance records did not show a record of this AD being complied with while it was active.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC) 
Condition of Light: Day
Observation Facility, Elevation: KPSN,423 ft msl 
Distance from Accident Site: 4 Nautical Miles
Observation Time: 12:15 Local
Direction from Accident Site: 341°
Lowest Cloud Condition: Clear 
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 60° 
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.32 inches Hg
Temperature/Dew Point: 16°C / 3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Anahuac, TX (T00) 
Type of Flight Plan Filed: None
Destination: Dallas, TX (1F7)
Type of Clearance: None
Departure Time: 10:45 Local 
Type of Airspace: Class G

According to FAA Special Airworthiness Information Bulletin CE-09-34 Carburetor Icing Prevention, at the time of the accident, the airplane was likely operating in conditions conducive to the formation of serious icing at glide power.

The estimated density altitude for the accident site was 194 ft above mean sea level.

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Serious 
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 31.713756,-95.677195 (est)

     


72 comments:

  1. Any aircraft that has been just sitting for a few years … this one 7 or 8 years … should be viewed as a big red flag by the pilot and mechanic.

    An aircraft like this needs an extensive thorough inspection and correction of whatever defects are found.

    So, will the mechanic/IA get to just skate on this one?

    ReplyDelete
    Replies
    1. Well, the attorneys will go after deep pockets and mechanics do not have them due to lack of insurance or low max amount policies.

      If the attorneys feel that there is money at the powerplant or accessory level that is where they will head.

      The A&P could come under scrutiny based on the records available, but in the end it is the deep pockets that are the target.

      If the mechanic had a policy it could be used to settle any action against the mechanic and to use those funds to go after the deep pockets.

      Delete
    2. I’m a retired A&P with an IA. I had my own shop and I have been the authorized inspector at an FAA repair station for many years. We specialized in maintaining Beechcraft piston engine aircraft. A Bonaza is not a simple airplane to annual. It requires you have two jacks and a tail stand or an anchor in the floor of the hanger to tie the tail down in order to properly inspect the landing gear.

      I see many irregularities in this NTSB report that concerns me. It appears that we are witnessing another example of an “Arm Chair” annual inspection, which require a recent (colored) picture of the aircraft in flight and a soft chair to sit in. Apparently even the lack of a recent color picture did not prevent the IA from signing this aircraft off.

      Did the IA jack the aircraft and cycle the landing gear? Was the battery dead. Did he have a power cart to cycle the gear correctly? Why was the placard missing on the fuel valve? It is impossible to claim the aircraft is airworthy with an inoperative generator. Why did he sign off the annual if the generator was inoperative? Why was the aircraft flown with the landing gear in the down and locked position? The lack of an operational generator would require a ferry permit. Was a ferry permitted granted for this flight?

      The new owner appears to be glossing over the fact that the aircraft was not inspected fully and the fact that he choose to fly a complex aircraft with a inoperative generator. It appears that the landing gear was unable to be retracted due to either mechanic problems or the lack of battery power.

      The ferry pilot is responsible for his own death by flying a known un-airworthy aircraft. There are so many negligent acts in this accident that it make your head spin. I would not be surprised if the FAA allows the IA to “skate” as mentioned above. We had several IA’s that floated around our airport “pencil whipping annuals all of the time. This act eventually put our repair station in an untenable financial position. How can you compete with an $100.00 annual? I hope the new owner and the IA have there licenses permanently revoked.

      Delete
    3. Absolutely agreed. Would like to see the paperwork for the pre buy and the annual

      Delete
    4. We those cheap annuals at our field too, not this bad in the case of this one, but in the end, they will still happen because many owners chase simple price over safety or legality, by choice or due to the fact they couldn’t afford it otherwise.

      Never seen jacks drug in during those inspections hmmm….

      Delete
    5. I'm a personal injury attorney. The ignorant comment above that the attorneys would just be looking for a deep pocket to sue displays a woeful ignorance of lawsuits. Whether there is money to pay a judgment is not a deciding factor. There must be liability, a/k/a fault, first. Without proof of liability there is no recovery possible. And that proof means showing that the party at fault was more than 50% responsible for the crash. A little fault gets no one nowhere.

      In this crash, the fault is nearly 100% on the two flying this dustbin. The A&P shares fault, but not even 50%. As the regs state - it is the pilot's responsibility to be sure the aircraft is airworthy. Here, the two know this piece of junk has been sitting for years. It is out of annual and nowhere close to being airworthy. Anyone remotely familiar with high performance singles knows this. You just don't park your butt in a high performance aircraft based on assumptions. Running the engine for 10 minutes to check it out was just ignorant. Not knowing how to position the fuel selector was just ignorant. (John Denver mistake). Trying to "brush the tree tops to slow down" was just ignorant. Chance of winning a lawsuit based on these facts would be zero. Anyone who filed a lawsuit based on these facts would be ignorant.

      Delete
  2. I wouldn't hop in a car that has sat for years and go blazing down an interstate - why people do this with aircraft is beyond comprehension.

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    Replies
    1. From what I read, the aircraft was inspected by a properly licensed A&P with IA ... so it does not sound like they "hop in" and go.

      Delete
    2. Did you read that there were no faults found on a plane that sat for 8 years??? Do you have any common sense???

      Delete
    3. I have a little and probably a lot more "aviation sense" than you do. My response was merely they had an inspection done and didn't just "hop in" as the initial idiot (maybe you) proffered

      Delete
    4. I’m an A&P with an IA. I have to compete with the guy willing to provide the best ‘inspection’ a few hundred dollars and a paper-mate pen can buy. There is no way one person can properly inspect a well maintained Bonanza in one day … much less one that has been sitting for years. Keep your rose colored glasses on if you like, but basically, they did just jump in and go.

      Delete
    5. I trust my mechanic but ever annual and every oil change is followed by me flying circles above the airport for an hour. Cheap insurance.

      -KV

      Delete
    6. This is an egregious example of a "hop in and go" flight. The two people, and the so-called IA are entirely culpable. It may be in a subsection of the FAR's that any screwdriver used as a plug in an aircraft line be properly secured with an FAA-approved radiator clamp.
      I once flew my old Piper Arrow for a "repositioning" flight of some 80 nautical with the gear down. My fuel usage was more than double what it would have been. I was young and indestructible at the time.

      Delete
  3. I’m a retired A&P with an IA. I had my own shop and I have been the authorized inspector at an FAA repair station for many years. We specialized in maintaining Beechcraft piston engine aircraft. A Bonaza is not a simple airplane to annual. It requires you have two jacks and a tail stand or an anchor in the floor of the hanger to tie the tail down in order to properly inspect the landing gear.

    I see many irregularities in this NTSB report that concerns me. It appears that we are witnessing another example of an “Arm Chair” annual inspection, which require a recent (colored) picture of the aircraft in flight and a soft chair to sit in. Apparently even the lack of a recent color picture did not prevent the IA from signing this aircraft off.

    Did the IA jack the aircraft and cycle the landing gear? Was the battery dead. Did he have a power cart to cycle the gear correctly? Why was the placard missing on the fuel valve? It is impossible to claim the aircraft is airworthy with an inoperative generator. Why did he sign off the annual if the generator was inoperative? Why was the aircraft flown with the landing gear in the down and locked position? The lack of an operational generator would require a ferry permit. Was a ferry permitted granted for this flight?

    The new owner appears to be glossing over the fact that the aircraft was not inspected fully and the fact that he choose to fly a complex aircraft with a inoperative generator. It appears that the landing gear was unable to be retracted due to either mechanic problems or the lack of battery power.

    The ferry pilot is responsible for his own death by flying a known un-airworthy aircraft. There are so many negligent acts in this accident that it make your head spin. I would not be surprised if the FAA allows the IA to “skate” as mentioned above. We had several IA’s that floated around our airport “pencil whipping annuals all of the time. This act eventually put our repair station in an untenable financial position. How can you compete with an $100.00 annual? I hope the new owner and the IA have there licenses permanently revoked.

    ReplyDelete
  4. what's with the screw driver sticking out of the hose in the engine compartment??

    ReplyDelete
  5. The mechanic who "purged the fuel tanks" and the pilot(s) who tried all three fuel selector feed positions during the 10 minute ground run were certainly aware before the trip that no detent functionality remained in the fuel selector valve. (The post crash valve check reported "Detents that should have been felt at the four selectable positions were not noted as the handle was rotated through the fuel tank positions.")

    And in that known discrepant/un-airworthy state, with diminished glide capability from flying with the gear down, they chose 1,800' MSL to try their luck on getting the selector valve positioned to where it would "look about right" and draw from a different tank, with no detent functionality to ensure success.

    Hard to believe that the attempt to get power restored could accomplish all of what was claimed as the Bo dropped from 1,800' MSL:
    "The fuel selector was brought back to the forward position, with no change. The fuel selector was then switched to the right fuel tank position, with no change. The crew tried to restart the engine on the right fuel tank with no success. The hand fuel pump was used when they attempted to restart the engine 5 or 6 times after the loss of engine power, with no success."

    Revoking certifications is a must-do for this one.

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    Replies
    1. While I want to see both the new owner (pilot) and the mechanic/IA have their license revoked I’m not holding my breath. Both the FAA and NTSB do not want to enforce their regulations on the General Aviation fleet. They seem to feel “it’s not worth the work”. I pointed out to our FAA repair station inspectors that one of our customers admitted to us that he did not have a medical because he has suffered a massive heart attach. The FAA tried to get met to make an enforcement. I gave them a written signed statement and they refused to investigate the matter. They watch him taxi his aircraft right past the restaurant with both FAA inspectors watching from their lunch table. I pressed the matter and the inspectors once again expected me to make an enforcement. When asked why or how that was to be accomplished they said, “I had to approach him and get him to admit he did not have a medical”. That made no sense to me and I realized that they were just blow me off. The FAA Flight Standards Districts Office in San Diego Ca was a joke full of mechanics that failed in the field and got hired by the government to regulate the rest of us hard working honest mechanics.

      We are seeing very poor quality investigations on many accidents from the NTSB. They don’t want to know what is going on in the maintenance facilities. They try to write off accidents at the flight operation (pilot) level.

      There is and always has been a number of mechanics that just don’t give a darn, they don’t make much money for their efforts and the industry is facing a crisis of retired mechanics. New hire mechanic are poorly prepared and the GA fleet is worn out and the parts are next to impossible to find for some engine/airframes. Thing don’t look good. I would not recommend a career in aviation maintenance.

      Delete
    2. Likely a “we will (supposedly) fix it at home” situation.

      If so, Hopefully the mechanic didn’t give into the pressure of them telling him that, and also hopefully not a regular thing for him/her either. Either way, he has opened himself up to liability or penalties.

      Delete
  6. I’d be will to bet $500.00 dollars that if you crack open those Bendix mags you will find the crappy old “white/burned yellow with heat” high tension coils. Those coil should have been remove by service bulletins back in the 1980’s. When these coils get hot they stop working very suddenly without any warning. I’m still finding them on aircraft currently. The level of awareness of flight safety is seriously low. Also the engine oil is coal black and the screen had unrecognizable debris. Not inspecting the engine oil screen is a serious offense. It appears the mechanic/IA did not perform any mandatory maintenance with him inspection. I’d like to know what his inspection check sheet looked like. How about you boys at the NTSB, did you bother to ask him for his inspection check sheet? That is mandatory!

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  7. That Bonanza was a real "Pig Boat." A true corrosion and rust infested Queen of 75 years, jimmy rigged and neglected that would require many, many thousands to repair. Couldn't have paid me enough money to climb into this Bone Yard Special and take to the sky. BTW, how the Hell does one restart an engine in the air with a non-functional generator and a dead battery, along with a broken fuel selector that wouldn't detent and had no placards?

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  8. Who paid to investigate and report in detail the obvious !

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  9. Note that fact that the propeller blades are virtually undamaged. That prop was not spinning on impact. How the hell do you get a constant speed prop to stop spinning>>>> by holding the nose high near stall speed for a long time. Everything about this accident has the words "Stupid" written on it. Cross country flight with the gear down, no generator, and unknown fuel system integrity. Clint Barnes the mechanic/IA should face criminal neglect, or man slaughter charges. He knowingly sighed off an annual inspection on an aircraft that he knew was going on a cross country flight. This was also a pre-purchase inspection to boot. It appears that he may have not opened cowl to look at the engine. How do you miss a screw driver shoved into a fluid/vacuum line? His logbook entry does not contain any references to any reoccurring AD''s How about the AD on the impulse couplings on the Bendix mags? It appears that the Aux tank was an option, did he have a form 337 in the records to reference to prove it was installed correctly. He claimed in his interview with the NTSB that the fuel valve placard was in place when he sighed the plane off. Where did it go? How do you sigh off a annual with non-operational generator and landing gear that won't retract. Why are they flying cross country with the gear down. This was clearly an un-airworthy aircraft that Clint Barnes knew was unsafe and a person lost their life because of his neglect. I sure as hell hope he is reading this sentence. The local district attorney needs to bring criminal charges against Clint Barnes!

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  10. Clint Barnes or no Clint Barnes (and personally, after reading this, I wouldn't let Mr. Barnes repair or inspect a shoehorn - much less an aircraft), these two unfortunate individuals made the decision to fly this airplane. Even the most nonchalant tire-kicker car buyer pops the hood and has a look at the engine even if they have no idea what it is they're looking at. As someone else commented, it would be tough to miss a screwdriver jammed into a vacuum or fluid line. Maybe that wasn't enough of a red flag to decide against actually getting this unit airborne, I don't know. As I am sure every reader of this blog knows, it is ultimately the PIC's responsibility to make sure the airplane is safe before taking off - what a shame that such a preventable event was set into motion and allowed to take place. There is so much wrong here it's mindboggling. Condolences to the friends, family, and loved ones of the deceased.

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    Replies
    1. Well said. We all take responsibility for our own lives when we get in an airplane, start it up, taxi out and put space between the wheels and terra firma. Even (and especially) a non-flying passenger needs to ask themselves how well do they know the capabilities and most importantly, the safety attitude of the PIC. If you have ANY doubt in your mind, STAY ON THE GROUND. An airplane ride, while fun, is not worth your life. It boggles my mind how little some people think about their own safety.

      Delete
  11. There are 4 ways an an aircraft of this category can be re-licensed (annual inspection) 1. A&P mechanic with an IA. 2. Approved repair-station. 3. Airframe manufacture. 4. FAA via a temporary ferry permit to a repair facility. In this case Mr Barnes sighed off the annual inspection with NO discrepancies. He released the aircraft to flying status, regardless of the option of others. Legally Mr. Barnes set this entire event into motion, had he not signed off the annual would they have flown the aircraft. I suggest that a jury would not allow Mr. Barnes off easy. The FAA needs to take action in this case. I have seen several cases much like this (to a lesser degree) and the FAA just lets the mechanic slide. It must come to a stop. Yes the pilot are responsible for the flying this aircraft but the letter of the laws was created to prevents un-airworthy from flying. Signing off a pile of junks is not within the letter of the law.

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  12. Whoever Clint Barnes is, hopefully he no longer has any FAA issued license, but who knows? At our local airport, we have a mechanic / pilot with a valid ATP certificate, a valid A&P certificate, and a valid medical who was convicted and did time for felony drug offenses AND burglary. He recently went BACK to jail for a parole violation. Guess what? I saw him at the airport today, working on a total rat trap older 310. The local FSDO absolutely knows that operators like this exist and they choose to do nothing about it. Because of their inaction AND because unscrupulous owners, operators, and mechanics continue to thrive in this business, the occasional fatality caused by a drive by annual and an incompetent pilot will continue to remain a staple of Kathryn's Report.

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    Replies
    1. Airmen Registry shows that Clint still has his IA.

      Delete
  13. As someone who owned a Bonanza for a number of years and had almost 1200 hours in it, the fuel selector detente was something that I always paid particular attention to when switching tanks. On mine, it was very apparent when the switch was in the groove and when it wasn't. Also, I personally would never fly 200 miles in a plane with the gear down because of a generator issue - if there were any issues that would have prevented things from working normally, I would have delayed and gotten them fixed. Additionally, I always considered it hard to find good mechanics to work on my plane the way I knew it should be cared for. The mechanic named was recommended to me once, and I chose to use someone else for personal reasons - I'm very glad I did.

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  14. Is the fuel valve REALLY mounted on oil/fuel soaked wood inside the cockpit????

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    Replies
    1. Oil soaked and stained birch OEM floor boards are the norm.

      https://www.bonanza.org/community/member-forum/maintenance/posts/jan-2010/floorboards/

      Delete
    2. Clipped from the above NTSB report:

      A review of the airplane’s maintenance records revealed that the most recent work performed before the pre-buy/annual inspection on the day before the accident was an annual inspection in August 2012. The mechanic reported there were no issues noted with the airplane during the annual inspection performed one day prior to the accident and the mechanic classified the airplane as “complete.” Before August 2012, annual inspections were performed in October 2010 and April 1994.

      In the preceding 27 years before the day of the accident this aircraft had exactly 4 annual inspections. That indicates that the aircraft was either never flown or it was flown illegally during this time. A review of the seller’s flight logbooks would be most interesting to see.

      This aircraft has been sitting around in a moist environment with virtually no maintenance for the last 27 years, yet it was passed a pre-purchase / annual inspection in one day with no discrepancies. Does the FAA feel this is a reasonable assumption?

      Delete
  15. Note also there were only two point restraints. There are many examples of fatal accidents were two point restraints failed to keep a pilot from hitting the instrument panel. While not required, I believe it is absolutely insane to fly a plane with only lap belts.

    Of course, this only one of the many ridiculous aspects of this flight as pointed out above.

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    Replies
    1. There is a glaring omission in the NTSB report. The seller/owner Mr. Lynn Davis was not interviewed nor was a written statement given by Mr. Davis.

      Since this accident revolves around the absents of the fuel selector valve placard and the lack of noticeable detents in the fuel selector valve, why did the NTSB choose to not get the testimony of Mr. Davis? As the registered owner of this aircraft, he would have known if the fuel sector valve placard and detents in the valve were present before the pre-buy/annual inspection.

      In addition, in the NTSB interview with Mr. Barnes (the A&P mechanic/IA) there is a comment made by Mr. Barnes that the “pilot” reported “the selector valve was confusing”. One is left to assume that the “pilot” is Mr. Davis ,the owner. Why was it confusing? Lack of a placard and detents would make it confusing.

      Also in the written testimony of Francis Roberts, (the buyer) reported that Mr Lynn Davis (the owner/seller) requested a “pre-buy inspection and that the necessary components be re-installed” as part of their negotiations of the sale. In the sales agreement between Mr. Roberts (buyer) and Mr. Davis (seller) the statement “make ready to depart” is stated.

      It appears that Mr. Davis, the (owner/seller) knew that the aircraft was un-airworthy during the time of the negotiations of the sale. The aircraft was inspected and prepared for the departure flight in Mr Davis’s hanger. The NTSB did not ask these important question of Mr. Lynn Davis.

      1. How long have you owned this aircraft?
      2. How many flight hours do you have in this aircraft?
      3. Has there been a fuel selector valve placard been in this aircraft during your ownership?
      4 Have you noticed the lack of fuel valve selector detents while flying or maintaining this aircraft?
      5. Was there any electrical system problems with this aircraft before or on the day of departure?
      6. Was there any problems with the landing gear retraction system before or on the day of departure?
      7. Was the main aircraft battery dead before or on the day of departure?
      8. Was the aircraft placed on jacks and a tail stand during the annual inspection?
      9. Was the landing gear retracted (cycled) during the annual inspection?
      10. Did the Mr Barnes (A&P mechanic/IA use an inspection check list during the annual inspection?
      11. Did Mr Davis receive a copy of the inspection form or was he informed of any discrepancies found during the inspection?
      12. Did Mr. Davis tell the mechanic “ the selector valve is confusing”?
      13 What components were re-installed on the aircraft?
      14. Was the aircraft “Hand Propped” to start the engine on the final departure?
      15. Why did Mr. Davis not require the aircraft be insured to protect his financial interest? The aircraft was sold on a 7 installment payment plan.

      Additionally, a review of Mr. Davis flight logbook would have given the NTSB a good idea how familiar Mr. Davis was with this aircraft. They may have been able to determine if the aircraft was flown at a time when the aircraft was un-airworthy. (out of annual inspection). This aircraft was out of annual in the preceding 8 years before the sale, with only 4 annual inspections in the last 27 years of service.

      Delete
    2. Look at the tach times in the logs:
      April 1994: 351.29
      October 2010: 399.5
      August 2012: 399.5
      March 2021: 411.29

      With those tach times, even a zealous rules enforcer would have no reason to inquire as to whether or not the out of annual time periods in years past included unauthorized flights. And Davis not requiring the buyer to have loss insurance would not be of interest to investigators.

      Mr. Davis's responsibility in the "make ready to depart T00" aspect may have provided the buyer a fresh battery (hard to tell battery age from the photo), but when Mechanic Clint Barnes signed his name to the logbook declaration of the Bo as airworthy, all of the airworthiness aspects in that list of questions became his to answer for, not Mr. Davis.

      FAA and/or NTSB weren't in a position to require or compel Mr. Davis to make a statement under those circumstances and you don't have to be an attorney to know that Davis would accrue no benefit from volunteering a statement.

      Delete
  16. Can't recall FAA ever revoking an A&P license for screwing up- maybe somewhere in the space-time warp it has happened. Aircraft was not placarded properly. This one required the mandatory placard: "Don't do anything stupid." Pilot's idea of "brushing the tree tops to slow down" was just stupid. They had a clearing to the left of the tree tops to begin the landing on terra firma. Then, they would not have dropped the 50' to the ground when it stopped flying in the tree tops. Ignorance of flight physics is a strict task master. Except for the death, this was a comedy of errors. RIP.

    ReplyDelete
  17. I agree, the FAA,seems reluctant to pull certification, claiming it will deny the person their ability to make a living. I know of one case where the mechanic lost his privileges for 6 months.

    The Texas state prosecute could take criminal negligence charges (possible jail time and or fines) against any of the three remaining participants, (A&P mechanic, seller, and buyer). The prosecutor must demonstrate that the defendant’s actions were so negligent and extreme that he or she should have known the possible risk of harming others. For example, annual inspection was performed in one day on a complex retractable aircraft that had not been inspected since 2012 and had accrued only 12 flight hours in that time period.

    The question is, was the ferry pilot, (PIC) Mr. LaRue Allen fully aware of the risk he was taking when he climbed in that Bonanza on March 06, 2021? Since he flew from the right hand seat, he would not have access to the fuel selector valve. Did he know the selector valve did not have a placard in place at the time of take-off? Cellphone records indicate that a text message was sent from the aircraft to the registered owner, Mr. Davis and 3 messages where returned back to the aircraft from the mechanic Clint Barnes, describing the relative position of the selector valve. One message asking “everything okay”. This messaging took place only a few minutes before the forced landing/crash. A reasonable person would not get into this sort of position risking their life if given the choice. That is what the jury must consider.

    Additionally the 3 individuals listed above could face a civil negligence lawsuit should Mr. Allen's relatives choose to take this path to recover financial damages.

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    Replies
    1. A civil negligence lawsuit in Texas is subject to determination of the percentage of responsibility, the "Proportionate Responsibility". A negligence lawsuit wouldn't be able to recover any damages at all if this PIC's percentage of responsibility is determined to be greater than 50 percent.

      The deceased pilot was brought in to do this flight as PIC because he had a high performance aircraft endorsement the new owner lacked. He was not a passenger or SIC relying on someone else that had primary responsibility to know how to operate the aircraft.

      For reference:
      https://statutes.capitol.texas.gov/Docs/CP/htm/CP.33.htm

      Delete
  18. A review of the NTSB accident report shows that the master switch was in the (On) position and all other electrical loads where turned to the (Off) position. The landing gear circuit had it circuit breaker in the “Pulled” position. Thus the down and locked green indicator lights would have been extinguished.

    The aircraft departed with a non-operational generator and what looks like a very tired automotive main battery. It appears the pilots where attempting to reserve the battery power in order to keep the fuel quantity indicators working.

    We don’t know if the battery was able to sustain sufficient power to keep the fuel quantity indicators working accurately.

    The accident investigators said all fuel tanks where empty. The 20 gallon Aux tank and the 20 gallon Right hand tank did not have any major leaks, the 20 gallon Left hand tank had at least one tear in the bladder. The fuel caps showed signs of blistering from aging and the fuel filler necks had corrosion on the sealing surfaces. The fuel lines where intact with no apparent leaking and they contained no fuel. The selector valve contained 1 ½ oz of fuel. No signs of fuel leakage was found on the ground, no fuel burns on the vegetation was detected at the crash scene. The fuel selector valve was found mid-point between two positions, in a position that would not allow for fuel flow.

    The pilot claims he loaded 54 gallons of fuel into the aircraft sometime before the flight. That is an interesting figure because the left and right tanks each hold 20 gallons of fuel which 17 gallons is useful from each tank. The 20 gallon Aux tank has 19 gallons of useful fuel. Thus 17 gallons + 17 gallon + 19 gallons = 53 gallons. It would be impossible to load 54 gallon of fuel into the aircraft. Perhaps some fuel was drained out via one or more of the sumps before the tanks where topped off.

    At any rate, the aircraft ran out of fuel 43 minutes into the flight. That’s quite the fuel burn! There are a least 3 possible conditions that could account for the fuel loss.

    1. That amount of fuel (54 gallons) was not loaded into the aircraft before departure.

    2. The fuel selector valve was selected to Aux tank at take off or soon after take-off.
    3. A combination of item #1 and item #2, but that is highly unlikely.
    The missing placard that should have been in-place would have stated >>> (take-off on left tank, burn 10 gallons of fuel before switching to Aux tank).<<< This is also in the pilots operational handbook which was not reported to have been found in the wreckage.
    If the Aux tank was selected at take-off or before 10 gallons had been consumed in the left tank it may have been possible for the fuel to have spilled out of the main tanks since the Aux tank feeds into the main fuel line, which could overfill the main tank(s). If the caps where blistered and the fuel filler neck sealing areas corroded then low air pressure caused by air flowing over the wings could have pulled the fuel out of one or more of the main fuel tanks and vaporized it. Thus some unknown amount of fuel could have been spilled overboard during that 43 minutes of flight.
    ******Continued on next posting below******

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  19. ******Continued from the above position ******
    Since the generator was turned to the (Off) position due to the fact it was non-operational, the tired old main battery may have run down to a point that the fuel quantity indicators were no longer working. The pilots may not have noticed or understood that the indicators where not accurate. The fuel may have been pulled out of the tank(s) and the indicators may have been indicating partially full. The need to make an emergency landing would not have been apparent to them at this point, so they continued to trouble shoot the fuel selector valve problem until it was too late.
    They where engaged in text messaging and having voice phone calls at this point trying to figure out how to position the fuel selector valve. It is possible that there was much confusion in the cockpit at this point.
    The radios where both in the (Off) position, perhaps with no electrical power at this point. They could not radio a May Day distress call without battery power and they did not have any navigational instruments functioning. They crashed 4.85 miles from Palestine Municipal airport on a heading of 200 degrees, their initially course was 310 degree as declared in the statement from the purchaser Mr. Roberts. Did they become lost in the final moments of their flight due to the lack of navigational instrumentation and a fuel management crisis? A course of 200 degrees put them on a course that took them away from an emergency landing field at the Palestine Municipal airport.
    It is interesting to recall that this aircraft was 11 years out from it’s previous annual inspection. At the time of the accident it had a non-functional generator, a non-functional retractable landing gear system, no fuel selector valve placard, no fuel selector valve detents, a tired old main battery, blistered fuel tank caps and corroded fuel filler necks sealing areas, and a screw driver plugging a fluid or vacuum line under the cowl, all of this one day after an annual inspection. The mechanic/IA claimed that no discrepancies were found during the annual inspection. That is a remarkable assertions!
    Just a reminder: Criminal Negligence that results in a death equals “Manslaughter”.

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    Replies
    1. > "very tired automotive main battery" Nope!

      The battery is an aircraft battery, Teledyne 7035-28, easy to view in Photo #2 and #8 of the docket's photo file. Probably new, charged before engine start. Can't get a 9+ year old aircraft battery that sat discharged since 2012 to recover and do anything at all. Mighty clean looking in closeup zoom of the docket photos.

      > "ran out of fuel 43 minutes into the flight." Nope!

      Flight was two hours. See 3.5.1 in Pers Elec Devices:

      According to the data extracted from the GPS72 (see Global Positioning System Specialist’s Factual Report) the accident flight was on March 6, 2021, from approximately 1020 to 1220.

      > "impossible to load 54 gallon of fuel into the aircraft." Nope!

      You didn't read about the mechanic having to purge the tanks. No reason to leave stale 2012 fuel in the bird. Tanks were emptied and rinsed before fuel was loaded on March 5 @ 4:51 PM (day before the flight) per fuel receipt in "Various Records".

      Also, you misunderstand how "usable fuel" relates to tank capacity when empty, which these were before the fill. Empty tanks can't get completely filled by putting in just the stated usable fuel quantities. Gotta first get the unusable fuel residual quantity loaded, then the usable fuel goes in from there on up.

      > On fuel caps/sealing: "some unknown amount of fuel could have been spilled overboard" Nope, not from caps.

      Examination reported no evidence of external fuel leaks was observed on the skin of the airplane. (Blue dye would have been prominent.)

      Please don't propagate incorrect assertions of a car battery, 43 minutes of flight when it was two hours, that the fuel quantity loaded was impossible or that caps might have leaked when report specifically checked and disproved it. Really undermines what you wanted to point out.

      Delete
  20. You are correct on all of your points, I am in error. I did not know of the existence of all of those facts and those documents and I had an incorrect flight time It did undermine what I’m trying to point out.

    Thank you for you timely and polite corrections.

    How to account for such a high fuel burn of approx. 26 gallon per hour and the fact that the pilot did not land and take on more fuel when only 5 miles for an airport. What happened to the fuel? If not the fuel caps leaking, and no fuel stains on the wings, did that Continental E-185 burn that much fuel? Did it leak out in some unknown manner?

    Could they have taken on fuel earlier in the flight had they know of their low fuel condition?

    A new battery would have lasted a 2 hour flight under such a light load. Were the fuel gauges accurate, where the gauges working? If they were burning fuel at such a high rate why did they risk running fuel tanks empty?

    Did the generator not work because it needed to have the field flashed to restore the residual magnetism? Sitting unused for many year would allow the magnetism to dissipate.

    Why are they flying a retractable aircraft cross country with the landing gear down? Why did they pull the circuit breaker, or why did it pop on it’s own?

    If they where not going use the comm radio, why not set the channel to the emergency frequency, just in case?

    I tried to find some explanation to some of these questions and I guess I failed miserably. It just does not add up what happened on this flight. What a waste of a persons life. LaRoe seems like he wanted to help his friend out and he got the short end of the stick.

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    1. Having details spread amongst the docket items makes some of it obscure, such as having to notice that the flight duration was somewhat buried in the personal electronic device data, but since the phone's location history is apparently how the investigation worked out the flight time aloft, that's where the info got lodged.

      Looking at that two hours aloft, which includes the unspecified time duration spent orbiting origin airport T00, the time aloft needs to account for the 132 nM distance flown from T00 to the Palestine area. Given the distance from origin to crash, there must have been more than just a short time spent orbiting T00 before heading out.

      Looking again at usable fuel, there was 3 gallons unusable of the 17 gallons that went into the empty left and also of the 17 that went into the empty right on the afternoon before the flight (and according to the new owner's statement, that fill at 4:51 PM was before the annual got underway, making the time spent on the "annual" much less than a day!).

      They got two hours aloft out of the combination of 14 gallons available left and 14 available right. At the two hours aloft point in time, they were trying to figure out how to begin drawing fuel from the aux tank.

      Burning through the 14 gallons usable from the left and the 14 from the right over a two hour period aloft while dragging gear is not excessive.

      We are left with the mystery of not finding the known to be loaded fuel in the aux tank or a reason it went missing, but the takeaway from this is that the long-idled hangar queen should have been moved by road on a trailer with wings stowed next to the fuselage, exactly is it had to be hauled away from the crash site. No need to lose a life before getting it on to a trailer.

      Delete
  21. Thank you! That was extremely helpful and insightful. Perhaps my errors prompted you to make those excellent corrections, it gave me new insights to this accident. I don't mind being wrong if someone learns from my mistakes. I greatly appreciate your response.

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    1. Yes, your look at the fuel mystery prompted an effort to make sense of the aircraft's fuel burn rate by looking closely at time associations. The extra digging thru the docket revealed the total time aloft. You are certainly being gracious about the corrections.

      Errors are easy to make. My earlier presumption that "data extracted from the GPS72" was related to cell phone location history is incorrect. Happened to search on "GPS72" just now and got it figured out. These guys had a Garmin GPS72 hand held GPS Navigator on board that was not mentioned in the preliminary report, nor was the specialist's report on GPS data from that device included in the docket.

      Kind of surprised that the final report doesn't state "Data extracted from a Garmin GPS72 hand held GPS Navigator on board the accident aircraft showed that after xx minutes spent in the pattern at Chambers County Airport, the aircraft flew toward the destination airport for yy minutes at a ground speed of zz knots".

      Similarly, seems like an investigative "miss" that there wasn't a detailed disassembly and examination of the fuel selector valve to understand whether the detent mechanism pin or ball was worn out, recessed into a broken spring and unable to extend or held recessed by old lube or fuel gum.

      Delete
  22. That is excellent detective work!

    Do you have any idea why they flew the aircraft cross country with the landing gear down? Would it be normal for the NTSB to ask such a question from a surviving crew member? I would think that this would be a very obvious question, especially since it is a major contributor to the accident, (fuel starvation).

    Did they pull the landing gear box and motor assemble for a detailed disassembly and examination? I would guess "no". Why did they not ask the mechanic/IA Chris Barnes if he put the aircraft on jacks and cycle the landing gear during the annual inspection? Why did they not ask Mr Barnes what he thought the reason was for the cross country flight with the landing gear down? Why such softball questions or no questions at all regarding what happens in the hanger before the flight with regards to the actions of the maintenance personnel?

    I started my investigation into this accident because I see a repeated pattern by the NTSB and FAA of not looking a maintenance related problems in General Aviation accidents and how the lack of oversight of the A&P mechanic/IA return to service (annual inspection) programs continues to feed the accident rate.

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    1. Presumably they flew gear down because the non-functioning generator put them in a position where the inability to charge the battery was a threat to being able to extend the gear at the destination.

      Delete
  23. Your discovery of the comment [clipped from your comment above]

    (and according to the new owner's statement, that fill at 4:51 PM was before the annual got underway, making the time spent on the "annual" much less than a day!).

    This supports my great concern that many aircraft are being returned to service by A&P mechanic/IA's without proper inspection methods and support tools. I've been watching this for over 40 years and it seems to be picking up speed again as General Aviation has experience a sudden reactivation in the last few years.

    A FAA repair station has an assigned FAA inspector with regular inspection schedule. A FAA approved repair station must has trained personnel and the required equipment at the facility to perform services for which they have approval. That includes things like jack stands, magneto test stands, magneflux inspection equipment, aircraft maintenance manuals etc. Contrast with the requirements of an A&P mechanic/IA working out of his or her pickup truck. They are required to perform 3 annual inspections per year and that is the total oversight. They bring in the little sheet with the N number of the aircraft they inspected and the FSDO rep. signs off their IA card, no further requirements. (at least this was the requirement when I held an IA in my own shop at the airport many years ago, which I relinquished due to the liability risk) This is why we see drive-by "Magic" annuals, and that is going to increase the death toll and severe inquires. This will also force FAA approved repair stations into insolvency and guys like myself that had all of the equipment and paid airport rent.

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    1. Cheapskate owners seeking to minimize cost of annuals by finding mechanics that do magic annuals impact the income of legitimate independent one-person A&P mechanics but may not take a significant amount of work from established shops. The relentless war on petroleum is likely to have a bigger impact on shop survival in coming years. Time will tell.

      Delete
  24. Let’s go back and visit the missing fuel problem for a while. I wanted to double check the fuel burn figures. I went to the American Bonanza Society web site to look at the fuel specifications.

    https://www.bonanza.org/aircraft-index/browse-by-type/bonanza/bonanza-35/

    They list the fuel capacity at 40 gallons of which 34 is usable. Each wing tank holds 20 gallons of which 17 gallons is usable fuel. The Aux Tank was 20 gallons of which 19 is usable. Thus 17gallons + 17 gallons + 19 gallons =53 gallons total usable fuel.

    I double checked these figures in the Pilots Operational Manual that is contained in the docket files. These figure are double checked at two sources and are correct.

    The flight time was 2.0 hours, both main fuel tanks ran dry in flight, for a total fuel burn of 17 gallons + 17 gallons = 34 gallons of total fuel burned. That equates to a burn rate of 17 gallons per hour.

    Can a Continental E-185 burn 17 gallons per hour? Even at full rich and dragging the gear that seem excessive but I guess it is possible, let’s say “yes”.

    There could be something wrong with the testimony of the new owner. Did they orbit for much longer before setting out on their cross country? Did they take a few extra test flights that where not reported?

    1. Was it possible that fuel was transferred out of the Aux tank into the left hand main tank during one of the test flights in some sort of mix up of the fuel selector valve positioning.

    2. Was the aircraft parked with the selector valve in the Aux position after a test flight and the fuel flowed in to the main tanks, leaving the Aux tank empty for the cross country flight. I don’t know if there is a fuel indicator for the Aux tank.

    Neither #1 or #2 sound completely correct, maybe someone else can come up with a plausible explanation.

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    1. Scroll up and read again about how 17 gallons loaded into each empty 20 gallon wing tank only provides 14 usable. Two hours of gear down time aloft at 14 gallons per hour (not 17) depleted the wing tanks, and they failed in the attempt to begin to draw aux fuel at the end of the two hours.

      Time to let go of the mystery of the aux tank's load gone missing. Unsolvable at this point from info available.

      Delete
  25. PERFORMANCE (ISA)
    Max cruise speed175 mph (152 kt)
    Max range (no reserve)750 miles
    Fuel capacity (standard)40 U.S. gallons (34 usable)

    Clipped from the bonanza website listed above: Usable is 34 gallon, that is 17 gallon from each tank. Usable is usable.

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  26. If the aircraft fuel capacity is 40 gallons total and the usable fuel is 34 gallons then the unusable fuel would be 6 gallons. If the tanks were run dry in flight then you would be put only 34 gallons of fuel back into the tanks. 6 gallons of fuel would be trapped within the tanks and fuel lines. Unusable fuel is not available to the pump or main strainer or the engine. If you removed the tanks and drained the fuel lines and installed new tanks you would be able to load 40 gallons of fuel back into the aircraft. Some how you want to add the unusable fuel back into the tank twice in your calculations. I'm very sure someone will correct me if I'm wrong.

    Never give up on an unsolved problem. It is unsolved because the correct approach to solving the problem has not been discover. How do you know if the problem is unsolvable at this point from the info available? All comment are being posted to you with the greatest respect. We are working on an interesting problem together my friend.

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    1. Since there is nothing difficult about understanding what the fuel ticket and circumstances of the drained tanks meant to the usable fuel quantity in the wing tanks, what could be the reason for not understanding after several responses were received that explain it?

      And then:

      > "Some how you want to add the unusable fuel back into the tank twice in your calculations. I'm very sure someone will correct me if I'm wrong."

      This seems familiar, saw something like that before...

      Same energy as this trolling lure from the Watsonville mid-air:
      "I’m not sure anyone in the entire thread is asserting “right of way”. I’m not sure i've seen that verbiage anywhere."

      Similarities...

      Delete
  27. I see where you have made an error. When the mechanic drained the fuel tanks the unusable fuel in the tanks remained. 3 gallons in each main and 1 gallon in the Aux tank for a total of 7 gallons of ususable fuel. This left room for 53 gallons of usable fuel to be added from the fuel truck into the aircraft >53 gallons + 7 gallons + 60 gallons total<. If you remember my first posting on this subject, I was concerned that the fuel load should have only been 53 gallons. It is possible that the mechanic was able to drain an addition 1 gallon of fuel by draining the gascolator, and at each tank's lowest point ( water removal) port for a grand total of 54 gallon load by the fuel truck, but only 53 gallons will be usable. It appears that the mechanic just open the gascolator and drained off the usable fuel and one additional gallon on the 3 tanks at the sump (water removal ports). The amount of fuel that can be drained at the lowest point (sump port) of the tanks depends upon the nose gear strut inflation pressure. High pressure will incline the aircraft nose high and allow for more water/fuel to drained at each sump port. The fuel pickup stand pipes in the fuel tank are usually responsible for the majority of the unusable fuel by design to trap water and sediment in the tank.

    You have a logic error running. For one main tank 17 gallons is usable, you don't subtract the unusable again to get 14 gallons. That is your error. You have a logic loop running in your explanation. If they added 54 gallons to the aircraft and the tanks can hold 60 gallons, then 6 gallons of fuel remained in the tanks after the mechanic drain off the old fuel. Only 53 gallons will be available in flight as usable fuel, leaving 7 gallons behind and unusable the next time the tank are topped off. I'm sure you are frustrated with me, please take the time to work this out in your mind. The aircraft hold 60 gallons of fuel, 53 gallons are usable, 7 gallons are unusable. That is what the a mechanic needs to know to perform a weight and balance computation, plus the moment for the weight of that fuel.

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    1. > "6 gallons of fuel remained in the tanks after the mechanic drain off the old fuel."

      Why would that ever happen? Opening or removing the sump check drain fitting is how a mechanic gets the 3 gallon residual out, not by using the fuel pickup that can't draw out the residual 3 gallons.

      This is not a serious discussion...

      Delete
  28. Yes, you are correct, removal of the sump check drains will get the unusable fuel out if the nose gear is not collapsed, but this mechanic did an annual in less that 1/2 of a day on a Bonanza. If he just opened the gascolator and drained the fuel, then the unusable fuel remained in the tanks. If he hit the sump check drains for a sample of part of the unusable and said "good enough" then you would get a useful load put back in by the fuel truck of 54 gallons. If the nose gear is collapsed then little of the unusuable fuel can be drained from the sump drain ports. Remember, this entire fuel cleaning and annual inspection, plus installation of unknown components took less than 1 day. Fuel can leave the tank in two paths, via the sump drain ports and or via the stand pipes, in flight the stand pipes give protection for contamination. One the ground sump drain ports remove contamination. If the mechanic drained out fuel by either method and only 54 gallons of fuel could be load backing into the aircraft then he drained out only 1 gallon of unusable fuel. Thus he did an incomplete job of removing the old fuel. This is a very serious discussion.

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    1. It's okay if you want to believe that the mechanic's fuel system drain and purge that didn't have the aircraft ready for fresh fuel until late in the afternoon of his working day was just a sump sample and left 3 gallons of 9 year old fuel in each wing tank.

      Similarity to Watsonville trolling for replies poster is strong in that.

      Delete
  29. No, what I'm saying is the fuel receipt is for 54 gallons of fuel as found in the docket. That means 6 gallons of fuel were remaining spread between the 3 tanks and fuel lines etc. We don't know how much unusable fuel was removed from each tank or the fuel lines, gascolator, or carburetor fuel bowl, just the simple fact that 6 gallons of unusable fuel remained in the aircraft. The total fuel load with a completely purged fuel system is 60 gallons. The computation is > 60 gallons total fuel load - 54 gallon = 6 gallon of that was left in the aircraft regardless of how it was drained by the mechanic. The mechanic left 6 gallons of old fuel in the system maybe because it would not drain out of the fuel sump check valves. If the nose gear is collapsed from 9 years of inactivity then the unusable fuel in the tanks will be shifted forward away from the sump ports making it impossible to drain this fuel regardless of the care he took in this task.

    ReplyDelete
  30. Lots of really stupid decisions here, but the one that takes the cake was the idea of "brushing across the trees' canopy" while approaching the chosen landing spot. A moronic idea if I've ever heard of one.

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    1. No kidding, dragging through the trees just before reaching the clearing you are planning to set down in is a great way to get pointed at the ground, lawn dart style.

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  31. It appears that the pilots were very busy in the last 10 minutes of flight, they were on the cell phone texting for assistance from the old owner and the mechanic on how to position the un-placared fuel selector valve. If it is true that the PIC (right seat) Mr. LaRoe Allen was flying up to the point of engine starvation and he swung the yoke over to SIC (left seat) Mr. Francis Robert, saying "it's your plane". Then SIC Roberts may have had less that a minute or two to take control and find a landing area while desperately pumping the aux fuel pump and twisting the un-placarded fuel selector valve around in circles hoping to find a way to restart the engine on his newly purchased Bonanza. His choices may have precluded any landing area other that the tree tops and he chose to make his statement in the report of "brushing across the trees" as a way making the best of the situation at the time. No one wants to make themselves look stupid in report that can be viewed by general public. Perhaps his choices where limited and he made the best of it. No doubt, given the opportunity he would have not taken the trees. He had considerable flying experience. Yes, many bad decisions lead up to this accident, which is not surprising, but he clearly would rather have landed at Palestine Municipal airport less that 5 miles from the crash sight and they had a hand help GPS, they may have been trying to get to that airport, but time ran out. I feel sorry for both of them. No one wants to kill their friend or severely injure themselves.

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  32. Flight time contradiction: (1).

    Contradictions in the NTSB docket reports.

    Information contained in the Garmin Hand help GPS GPS72 placed the total fight time of the accident flight at 2.0 hours, but the testimony of the new owner SIC Mr. Francis Roberts said that 43 minutes into the flight, while selecting the Aux tank the engine quite.

    If using the GPS data, cross country portion of the flight was 43 minutes and local orbiting flight portion last 1 hr. 12 minutes. If using Mr Robert testimony, the flight lasted 43 minutes.

    This contradiction needs to be considered when calculating fuel burn in gallons/hour. Which flight time is correct?

    ***********************************************************************

    Clipped from Docket document:

    NATIONAL TRANSPORTATION SAFETY BOARD
    Vehicle Recorder Division
    Washington, D.C. 20594
    April 6, 2022
    Personal Electronic Devices
    Specialist’s Factual Report
    By Nick Swann

    According to the data extracted from the GPS72 (see Global Positioning System
    Specialist’s Factual Report) the accident flight was on March 6, 2021, from approximately
    1020 to 1220.

    *************************************************************************

    Clipped from

    Michael J. Hodges Air Safety Investigator Central Regional Office Office of Aviation Safety National Transportation Safety Board Date: 03/18/2021 Person Contacted: Francis Roberts (Co-Pilot – N3394V, Beech 35) NTSB Case Number: CEN22LA151 Narrative:

    The following is a synopsis of the information provided by Francis Roberts to the NTSB investigator-in-charge, via a telephone conversation:

    • About 97 minutes from the destination airport (about 43 minutes into the flight), the crew decided to switch the fuel tank from the left fuel tank to the right fuel tank. Instead, they then decided to use just the auxiliary fuel tank instead. Page 2 of 2 • While switching to the auxiliary fuel tank, a loss of engine power occurred. • The fuel selector was brought back to the forward position, with no change. The fuel selector was then switched to the right fuel tank position, with no change. The crew tried to restart the engine on the right fuel tank with no success. The hand fuel pump was used when they attempted to restart the engine 5 or 6 times after the loss of engine power, with no success. • During the forced landing, Francis flew the airplane because he wanted to take responsibly for his airplane. His intent was to impact the top of the trees and then land into the trees.

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  33. Big potential resale value in those ruddervators from a hangar-kept 35 if the recovery outfit didn't damage them during haul out. Looks like the ruddervators didn't suffer any damage in the crash. Gotta hope no corrosion was found and another Bonanza has them installed by now.

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  34. The cause of this accident should be changed from “Fuel Starvation” to “Missing Placards”.

    There are conflicting accounts from the mechanic/IA Mr. Chris Barnes, SIC Mr. Francis Roberts, and the docket report file investigating team from Textron Aviation. The mechanic and the SIC reported that the fuel selector valve placard was installed. Textron Aviation said the placard was not found in the wreckage and probably was not installed.

    During the last 10 minutes of flight, a text message was sent to the former owner Mr Lynne Davis requesting assistance on how to operate the fuel selector valve. The mechanic Mr. Barnes replied with three text messages, two of which described how to position the selector valve to allow SIC Mr Robert the selection of the 20 gallon Aux tank. There was a voice conversation on the same phone in the aircraft for a little over 2 minutes after the text messages. A few minutes after the phone conversation the engine quite due to fuel starvation of the left hand tank.

    This aircraft requires two placards be installed at the fuel selector valve, not one.

    It is possible that one of the two placards was in place but this is unlikely since the mechanic described how to aim the selector valve in the various clock positions in two of the three text messages.

    One placard shows the relative position of the valve in relationship to: “Forward = Aux tank” “Left =Left tank” Right = Right Tank” “Aft = Off”.

    The second required fuel selector valve placards reads:

    TO SELECT TANK
    PUSH HANDLE
    DOWN, ENGAGE
    VALVE AND TURN.
    KEEP HANDLE
    ENGAGED WHEN
    NOT PUMPING

    The fuel selector valve on this aircraft is a combined pump and selector valve. The selector valve is a complex device, it require that the handle be fully depress down (locked) to function as a selector valve. When the handle is pulled upward it disengages from the selector valve function and switches to an emergency hand fuel pump function.

    The post accident investigating team from Textron Aviation found the valve handle pulled up ½ inch into the pump position function, and turned between two valve positions preventing fuel flow.

    The lack of one or both of the required placards deprived (SIC) Mr. Roberts from understanding that the valve must be fully depress in order to select various tanks and the “OFF” position.

    (SIC )Roberts tried unsuccessfully to restart the engine five or six times. (SIC) Roberts reported that he had 20 gallons of fuel in the Aux. tank and 17 gallons of fuel remaining in the Right tank after the accident. His statement corresponds correctly with the flight time calculated from the Tach time after the accident against the Tach time from the day before, taken from the logbook annual inspection. This calculated to equal 1.61 hours. The fuel burn calculated at 17 gallons usable fuel in the left tank divided by the Tach time of 1.61 hrs = 10.55 gallons/hr. fuel burn rate. GPS recorded flight time was exactly 2.0 hour, which is a reasonably close correspondence with the Tach time of 1.61 hrs.

    It is the responsibility of the A&P mechanic/IA to require that both of these placards be in-place before returning the aircraft to airworthy statues during an annual inspection which happened to be the day before the accident.

    RIP Mr. LaRoe Allen.

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  35. Among the mistakes, the low travel altitude stands out. Flew at 1,800' MSL. Elevation where the fan quit was about 400 MSL, so 1400' AGL. Lucky to be near KPLS, but no joy, hit the ground short by 4 miles. Map view of where the bird ended up has open areas big enough that this would have easily ended better from just a bit more travel alt.
    http://maps.google.com/maps?t=k&q=loc:31.713841+-95.677135

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  36. I wonder if they were bucking a strong northerly wind? Palestine's airport main runway is 360 - 180. March can be windy in Texas. Dragging the landing gear with a head wind may have been why they were done low. Very bad idea right after a "Magic" annual inspection.

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  37. Bonanza 100 hr. / Annual Inspection Check List:

    For anyone that maybe interested I had attached the URL of the 100 hr. annual inspection check list that we used in our FAA repair station when we did either inspection. If you view this document you will clearly understand that it is impossible to properly inspect any Bonanza in 1 day regardless of the condition of the aircraft.

    https://www.bonanza.org/contentassets/24234209bbec4fad8922c22204a71f83/bonanza-annual-inspection-compact.pdf

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  38. The fuse was lit for this "accident" on the day of the sale and nothing was going to put it out.

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  39. I agree, even if they got this aircraft back in the new owners hanger, sooner or later something would have taken it out. This plane had a steady diet of "Arm Chair" annuals. Since the new owner thought another one would be just fine you can see that he has no understanding of the complexity of a good airworthiness inspection.

    In Mr. Roberts written testimony and phone call conversation with the NTSB, no mention is made of the text messages about trying to figure out how to position the fuel selector valve or the contents of the phone call they had minutes before the engine quit. There are other "errors and omissions" in his testimony. Another example, in one location he claims that 17 gallons of fuel remained in the RH tank, in another he claims 13 or 14 gallons remained in the RH tank. What is it? Did he use that tank or not?

    Probably the most interesting thing about this accident is the "Missing Fuel" problem. It looks like they burned off the LH tank entirely, and maybe they burned off 4 or 5 gallons of the RH tank, then they tried to switched to the Aux tank. If you look at the selector valve placard, you have to point the valve handle "FWD" for Aux. But that is not intuitive at all. FWD would look like "Off" without a placard. They put the valve someplace other than one of the normal positions. The engine quit, they were not running carburetor heat. The conditions were perfect for carburetor ice and they were running rich to keep the cylinders cool. When they lost the fire the ice took them out.

    Post accident investigation by the two contractors (Lone Star and Textron) said that no fuel could be found in the fuel lines or any of the 3 tanks. Now the "Missing Fuel Problem" appears. Textron said, only the LH badder tank had holes, the RH tank held water. Textron DID NOT leak test the AUX tank.

    What happened to the 20 gallons of fuel in the Aux tank?

    What happened to the 13 or 14 gallons of fuel in the RH tank?

    Textron said no leaks could be found in any of the fuel lines. The selector valve was found in a positioned between two tanks and no fuel could flow. So the selector valve would not allow fuel to leak out after the accident.

    If you assume the Aux tank and RH tanks leaked out from a breach then the "unusable fuel would be in the tanks, 3 gallons for the RH tank and 1 gallon for the Aux tank. What happened to the "Unusable Fuel"?

    Does this airplane have MAGIC gas too.

    There was no tear down of the fuel selector valve either. If you push down on the pump /selector valve handle hard, it will engage the selector valve function and the detents may have been detected. We don't know if they pushed the handle down since there is no tear down examination or discussion in the report. This appears to be a sloppy examination of the critical component that caused the accident.

    Give all of this some thought. What out-come did the NTSB want in their report?

    1. Fuel starvation (caused by the pilots),
    2. Negligence (caused by the mechanic/IA)?

    This accident was caused by a the lack of two fuel selector valve placards. It was the sole responsibility of the A&P Mechanic/IA to make certain that these placards where in place. The annual inspection was completed the day before the accident, in a time period of less that 1/2 day.

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  40. Interesting that the new owner had two PA-28R-180 aircraft before the Bonanza, N5368T from 2009 through 2019 and N270FR from August 2020 through August 2021. Had a PA-28 N5303W before those retract birds. No crash history or incidents show up for his ownership of those three.

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  41. Thank you, that is useful information! Yes, the pilot made a mistake in the choice of people and procedures to inspect his aircraft not a lack of pilot skills. Anyone with his experience should have know better, but in the end it was the mechanics lack of due diligents in his inspection that left the pilot without the critical knowledge of how to use a complex fuel pump/selector valve, NOT fuel starvation.

    Many people are criticizing him for his landing in the trees. He had no other choice and planned to stay in the tree canopy, but his speed and energy carried a bit to far. Yes he flew too low, but as mentioned above, he may have been bucking a strong headwind while dragging the gear.

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