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Pilot’s mismanagement of fuel system proves fatal

By General Aviation News Staff · January 22, 2025 · 12 Comments

On Jan. 6, 2023, about 17:52 central standard time, a Beech M35 was destroyed when it was involved in an accident near Fayetteville, Arkansas. The pilot was fatally injured.

Automatic Dependent Surveillance–Broadcast (ADS-B) data revealed that the airplane departed Drake Field Airport (KFYV) in Fayetteville, Arkansas, at 15:31 and proceeded to Stuttgart Municipal Airport (KSGT) in Stuttgart, Arkansas, arriving at 16:29.

A pilot-rated passenger, who was on board during this leg of the trip, reported the flight was routine and there were no issues with the airplane. The pilot informed him the airplane was fully fueled before departure from KFYV. It was not fueled while at KSGT. The pilot-rated passenger and a second passenger disembarked and did not accompany the pilot on the return flight to KFYV.

The pilot departed KSGT at 16:49 and proceeded on a northwest course direct to KFYV, climbing to a cruise altitude of 4,500 feet mean sea level (MSL).

At 17:46, about 18 miles southeast of KFYV, the airplane entered a descent as it remained on course direct to KFYV. The average airplane descent rate during this time was about 425 feet per minute.

About 17:52:22, the airplane entered a left turn from an altitude of 1,875 feet. It remained in the left turn until the final ADS-B data point at 17:52:33. The altitude associated with the final data point was 1,625 feet MSL. The airplane was on a south course, about 170°, at that time.

The pilot had contacted the KFYV tower and informed the controller that the airplane was about 10 miles from the airport. The controller instructed the pilot to enter a left downwind for Runway 16 and cleared him to land. He acknowledged the instructions. No further communications were received from the pilot.

A witness reported hearing the airplane as it approached. He recalled that the engine sounded as if it was going to lose power but then “revved up really high.” This cycle occurred three or four times over a span of 10 to 15 seconds.

The engine seemed to stop, however he was unsure if the airplane had simply descended behind a ridgeline. He did not hear the impact nor was he able to see the airplane.

The airplane hit trees and terrain about 185 feet south-southeast of the final ADS-B data point, which was about three miles from the destination airport. The airplane impact path was toward the southeast and it came to rest upright.

The engine, firewall, and instrument panel were partially separated from the airframe and the cockpit area was compromised. The center fuselage was deformed, and the aft fuselage was partially separated. Both wings remained attached to the fuselage and exhibited leading edge crushing damage. The empennage remained attached to the aft fuselage.

The Beech M35 was equipped with two 25-gallon main fuel tanks, one installed in each wing. In addition, the airplane was equipped with two 10-gallon auxiliary fuel tanks, one installed in each wing outboard of the main fuel tank.

The fuel selector valve was located near the pilot’s seat. The selector had settings for the left main tank, the right main tank, and the auxiliary tanks. The main fuel tanks were selected individually. Both auxiliary tanks were connected to a common port on the fuel selector and fed simultaneously when selected.

Excess (unburned) fuel from the engine was returned to the selected main fuel tank or, if the auxiliary tanks were selected, to the left main fuel tank.

After the crash, investigators found the fuel tank caps were securely installed and each tank appeared to be intact. About 15 gallons were recovered from the left fuel tank and 10 gallons from the right main fuel tanks. Both the left and right auxiliary fuel tanks contained minimal fluid. The fluid recovered was clean, free of debris or sediment, and exhibited a blue tint consistent with 100LL. The fuel selector was positioned to the left main fuel tank at the time of the examination.

The airplane was equipped with an electronic engine display unit. The data indicated the fuel tanks — both main and both auxiliary tanks — were full or nearly full upon departure from KFYV.

After takeoff, the right main fuel tank quantity decreased slightly and then remained stable for the duration of the flight. The left main fuel tank quantity then began to decrease steadily, consistent with the left main tank being selected.

About mid-flight, the auxiliary fuel tank quantities began to decrease and the left main tank quantity began to increase, consistent with the pilot changing to the auxiliary fuel tanks.

Upon departure from KSGT, the right main fuel tank quantity steadily decreased for most of the flight. Beginning about 17:38, the right main tank quantity remained constant while the left auxiliary tank quantity began to decrease consistent with the pilot selecting the auxiliary fuel tanks. The left main fuel tank quantity began to increase, which was also consistent with selection of the auxiliary fuel tanks.

About this time, the right auxiliary fuel tank quantity dropped out and remained at zero for the duration of the data. Shortly afterward, the left auxiliary fuel tank quantity dropped out and remained at zero for the duration of the data.

About 17:50, the fuel flow became unstable until it abruptly decreased to zero about 90 seconds later. The fuel flow remained at or near zero for the remainder of the flight. The fuel quantities recorded by the engine display unit at the end of the recorded data set were 25 gallons in the left main tank, 8 gallons in the right main tank, and zero gallons in both auxiliary tanks.

The recorded data ended about 17:52:19, which was about 14 seconds before the final ADS-B data point.

Probable Cause: The pilot’s mismanagement of the airplane’s fuel system, which resulted in fuel starvation and a loss of engine power.

NTSB Identification: 106548

To download the final report. Click here. This will trigger a PDF download to your device.

This January 2023 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

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Comments

  1. Chris Fosse says

    January 25, 2025 at 9:41 am

    Always keep your pattern tight enough to be able to reach the runway if you lose power. That was drilled into me during initial flight training. What is happening to flight instruction these days as we see all these 747 patterns?

    Reply
  2. Bob Hearst says

    January 25, 2025 at 9:32 am

    The old “G” model Banana with tip tanx rings that Bell !!!!

    Reply
  3. Michael Vivion says

    January 25, 2025 at 8:02 am

    There’s nothing wrong with running a tank dry, as long as the PIC UNDERSTANDS the fuel system, and keeps those tank changes and exhaustion to appropriate times and parts of the flight. I can’t even imagine how many times I ran tanks dry in Beavers…..SOP. My Beaver Check out performed by one Jack Corey “Run that tank dry, switch to another, and you’ll never go back to that dry tank, thinking there MIGHT be “enough” gas left there to save your butt.
    Know your airplanes fuel system thoroughly, and operate it intelligently.

    Reply
    • Bruce Hinds says

      January 25, 2025 at 10:14 am

      Yes sir, we did the same in Beech 18s and DC-3s. That was standard procedure.

      Reply
  4. Ceplecha Christopher says

    January 25, 2025 at 6:20 am

    Fuel systems in a large percentage of light GA aircraft are poorly designed and unnecessarily complex. Cessna seems to be the only company that developed a “both” position in their single engine aircraft, which is basically a set and forget position. Some later light twins of many manufactures also have pilot friendly designs with large single tanks feeding to their respective engines. But some aircraft have fuel systems designed that makes them a fuel management nightmare. Here’s a thought. Design fuel systems that reduce fuel management errors. On single engine aircraft that is as simple as a both position, or having the left and right tanks plumbed into a single feed tank that feeds into the engine. Come on engineers, it’s really not that hard. Many fuel system designs are as poorly thought out as the single dry vacuum pump supporting vital attitude instruments concept. I despise crappy designs that fail to take into account simple human error.

    Reply
  5. Cary Alburn says

    January 23, 2025 at 6:49 am

    Seems like an overly complicated fuel system, but the issue I’m seeing is that the pilot apparently felt it necessary to drain the tanks before switching to fuller tanks. Even with a less complicated fuel system, that’s a mistake. When the engine dies due to fuel starvation, it can take what seems like forever to restart after switching to a fuller tank. And that “forever” may be just long enough that it ends the flight prematurely, if the starvation occurs at relatively low altitude. I have read several reports in which that happened, typically because the tank-switching was done on downwind in the pattern.

    Reply
    • JJ says

      January 23, 2025 at 9:38 am

      I learned, the easy way, that on my D-35 V-tail, that if a tank is drained dry, and the fuel lines are dry, even with the rest of the tanks being full, the wobble pump, electric aux pump, and the engine driven pump can not get fuel to the engine until they are primed. This was discovered after replacing the fuel line from the left tank after new fuel bladders were installed.

      Reply
    • JimH in CA says

      January 23, 2025 at 5:39 pm

      Add the 2 tip tanks and you’ve got 6 tanks to manage… not difficult if you follow the POH procedures….and also remember which tank the return fuel go into, so you don’t dump fuel overboard.!! The left tank had 25 gallons, and how much went overboard.?

      I appreciate my Cessna ‘both’ selection more every week.

      Reply
  6. Are Cie says

    January 23, 2025 at 6:27 am

    Unless he selected the left main after the engine quit, & didn’t get a restart, it would seem the fuel was managed properly as the article states the selector was on the left tank, and later states 25 gallons in the left tank.
    What am I missing?

    Reply
  7. Scott Patterson says

    January 23, 2025 at 4:39 am

    Confusion;
    Visual, fuel selector in left tank position.
    Visual, 15 gallons in left tank.
    Where’s the fuel mismanagement?

    Reply
    • NickS says

      January 23, 2025 at 6:28 am

      Ditto. These reports would be much more helpful if they made any sense.

      Reply
  8. Richard says

    January 22, 2025 at 10:29 pm

    Well he we go again, “pic” not paying attention, or kept using the “auxiliary tanks” instead of main tanks! It seems he has enough fuel in all of the tanks to finish the flight. Why, did he use the auxiliary tanks, when he had enough in the main tank (s)?
    Unfortunately we will never know.

    Reply

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