Aviation Accident Summaries

Aviation Accident Summary NYC93FA169

MEDFORD, NJ, USA

Aircraft #1

N3804B

BEECH F35

Analysis

A FLIGHT INSTRUCTOR, WHO HAD JUST COMPLETED A FLIGHT IN THE AIRPLANE, REPORTED THAT BOTH MAIN FUEL TANKS WERE DOWN TO ONE QUARTER FULL, AND THE AUXILIARY TANK WAS AT THREE QUARTERS FULL. DURING REFUELING, THE PILOT OF THIS FLIGHT HAD ONLY THE LEFT TANK FILLED. THE PILOT AND PASSENGER DEPARTED ON A LOCAL FLIGHT, AND AFTER ABOUT 1 HOUR OF FLYING TIME THE PILOT TRANSMITTED ON UNICOM THAT THE ENGINE HAD LOST POWER. AFTER SEVERAL SECONDS HE TRANSMITTED THAT THE ENGINE HAD REGAINED POWER MOMENTARILY AND THEN QUIT AGAIN. THE PILOT ATTEMPTED A FORCED LANDING TO THE AIRPORT RUNWAY, STRUCK A TREE, NOSED OVER AND IMPACTED SEVERAL OTHER TREES. POST ACCIDENT INVESTIGATION REVEALED THE FUEL SELECTOR WAS ON THE RIGHT TANK. THE RIGHT TANK CONTAINED 9 OUNCES OF FUEL WHILE 12 1/2 GALLONS REMAINED IN THE LEFT TANK AND 7 1/2 GALLONS REMAINED IN THE AUXILIARY. THE ENGINE WAS PLACED ON A TEST STAND WITH ALL ORIGINAL COMPONENTS. THE ENGINE STARTED AND RAN WITH NO NOTICEABLE DEFICIENCIES. THE ELECTRICAL BOOST PUMP ALSO OPERATED WHEN TESTED. THIS WAS THE PILOTS SECOND FLIGHT AS A PIC IN THIS TYPE AND MODEL OF AIRPLANE.

Factual Information

HISTORY OF FLIGHT On Sunday, August 22, 1993, at 1545 eastern daylight time, a Beech F35, N3804B, piloted by Terrance Chamberlain, was substantially damaged when it struck trees and impacted the ground during a forced landing, near the Flying W Airport, Medford, New Jersey. The pilot and passenger were fatally injured. Visual meteorological conditions prevailed. A flight plan had not been filed for the flight operating under 14 CFR 91. A flight Instructor and student pilot had just completed a training flight in N3804B prior to Mr. Chamberlain's flight. In a witness statement, the flight instructor stated: "...Prior to our departure we did an extensive preflight...we drained all six drains and did not notice any water or visible impurities...we proceeded to start the aircraft...the mags were checked twice and the prop was exercised a few times...everything appeared to be normal...I flew a total of 1.4 hours this date with the student and my flight was good with no problems. The aircraft performed as expected...I met Dr. Chamberlain and told him the plane was low and needed fuel...I called for fuel...Dr. Chamberlain then went to meet the fuel truck...." In an interview with the Flight Instructor, he stated that at the completion of his flight, both the left and right main fuel tanks were indicating about 1/4 full, and the 20 gallon auxiliary tank was indicating three quarters full. According to the refueler's statement, when he arrived to refuel the airplane, he filled the left main fuel tank. Then as he went to fuel the airplanes right tank he was told by Mr. Chamberlain, "do not even touch it." No other fuel was added. At about 1300, Mr. Chamberlain and a passenger departed the Flying W Airport in N3804B. The Hobbs meter time recorded prior to departure was 1479.62. The airplane destination was not determined. Post accident examination of the tachometer revealed a Hobbs meter reading of 1480.62. At approximately 1540, several pilots flying in the area reported hearing N3804B transmit on the airport unicom frequency that he was having engine trouble. In a witness statement, Harry Kirkhope stated: "I was enroute to Flying W from the north...I had just tuned in the unicom when I heard an aircraft state that he was a Bonanza, his engine quit and he would like a straight-in for runway 01...[The] pilot reported he was 7 1/2 miles out and airport in sight, I believe he stated he was at 2,700 feet. Less than a minute later he reported his engine had restarted...shortly thereafter, he reported the engine quit again." A pilot who landed just ahead of N3804B stated: "...he [N3804B] announced he had restarted the engine. Just before I touched down he came back to say his engine was again out...he was 2 miles out at 1800 feet. I...turned off at the first taxiway and watched for the aircraft. I first saw the aircraft approximately 1 mile out at about 800 feet. The gear was down and there was at least one notch of flaps...It appeared to be a standard approach...I could not see the last 1/4 mile of the approach but it appeared...that the prop was not turning and the aircraft was level... not nose down as in a standard approach but more like trying to hold the nose up." The airplane struck trees and impacted the ground about 750 feet short of runway 01, at the Flying W Airport. The accident occurred during the hours of daylight, at approximately 39 degrees, 56 minutes north latitude, and 74 degrees, 49 minutes west longitude. PERSONNEL INFORMATION The pilot, Dr. Terrance Chamberlain, held a Private Pilot Certificate with a rating for airplane single engine land. His most recent Federal Aviation Administration (FAA) Third Class Medical Certificate was issued on March 19, 1992. At the time of the accident Dr. Chamberlain had accumulated about 349 flight hours. This was his second flight as a Pilot-In-Command of any Beechcraft Airplane. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on August 23, 1993, and removed to a local hangar for further investigation on August 24, 1993. The examination revealed that all major components of the airplane were accounted for at the scene. The airplane came to rest upright in a swampy, wooded area, with thick undergrowth, on a magnetic bearing of 040 degrees. Initial tree impact scars started approximately 102 feet from the wreckage. The scars became progressively lower on the trees in the direction of the wreckage. The tree scars indicated a general direction of 013 degrees. A tree furthest from the wreckage, had an approximate 15 foot section broken and hanging down from the top of the tree. A branch of the tree top was missing. A 4-foot long, by 5-inch diameter tree limb was found on the ground, 27 feet south of the main wreckage. A 6-foot long by 5-inch wide rip in the bottom of the airplane fuselage contained pieces of wood and bark similar to the 4-foot tree section. The airplane came to rest in an approximate 30 degree nose down attitude. The main landing gear was found extended and intact. The nose wheel was separated and found just aft of the left main landing gear. The left wing was sheared off outboard of the left main landing gear and found 14 feet aft of the fuselage between two trees. The engine remained attached to the fuselage. Visual inspection indicated no abnormalities except for a cracked oil tank and carburetor flange. The propeller blades were attached to the hub and engine. The blades were curved backwards and showed no signs of chord wise twisting or scratches. There were no noticeable nicks or gouges on the propeller blades leading edges. The flaps were in the retracted position. Flight control cable continuity was established from the cockpit to all control surfaces. The airplane was equipped with a single column, dual yoke control. Both arms of the control column were broken. The cockpit and cabin integrity was not deformed. The panels on the left and right side of the dash board were dented forwarded. The airplane was not equipped with shoulder harnesses. The fuel selector was found selecting the right main tank. The wobble pump handle was partially extended. There was no fuel odor and no visual fuel leaks. The nose of the airplane was raised and the fuselage was leveled at the accident scene. Fuel then began dripping from the auxiliary tank vent line. The fuel tanks were drained into containers. Eight fluid ounces were drained from the right main tank, 12 1/2 gallons were drained from the left main tank, and 7 1/2 gallons were drained from the two 10-gallon interconnected auxiliary tanks. An undetermined amount of fuel was vented from the auxiliary tank during draining. The fuel was blue in color. When tested with "water finding paste", it was found absent of water. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were performed on Terrance Chamberlain and Janet L. Decleyre, on August 23, 1993, by Dr. Joseph De Lorenzo, of the Burlington County Medical Examiners Office, Burlington, New Jersey. The reports stated that the pilot and passenger died of, "multiple injuries secondary to airplane crash." Additionally, the reports stated, "There are multiple diagonal superficial friction abrasions on both anterior iliac areas which appear to be from the seatbelt." The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, revealed negative for drugs, carbon monoxide, cyanide and alcohol for Dr. Terrance Chamberlain. TESTS AND RESEARCH Fuel System Testing: The engine was detached from the fuselage at the accident scene and removed for further testing. The wreckage was removed from the scene to a hangar and blocked level. One additional ounce of fuel was drained from the right main tank. The fuel selector was set to the right main tank. When the wobble pump was stroked several times, less than one ounce of fuel discharged from the fuel selector outflow line. The outflow line from the fuel selector was disconnected. Three gallons of fuel were added to the right main tank and no leaks were observed from the tank or lines. When the fuel selector was placed to the right tank, a slight fuel flow started from the selector valve outflow port. The fuel line was reconnected and the wobble pump was stroked once. Fuel was observed to flow freely from the fuel line that had attached to the engine fuel pump. The fuel selector valve was removed from the airplane. Compressed air was blown into the fuel outlet port of the selector. Air was felt discharging from corresponding fuel inlet positions as they were selected. No foreign material was observed discharging from the selector valve. Engine Testing: The engine was shipped to Mattituck Airbase Inc., Long Island, New York, as removed from the wreckage. The engine was placed on a test stand with a test propeller installed. A remote oil tank was connected to replace the cracked oil tank. A fuel line, electrical power, and a start switch were attached. The engine was primed, and started on the first attempt. The engine was warmed up at 1300 RPM. At 1800 RPM a magneto check produced an approximate 110 RPM drop on the left and right magnetos. The engine was run up to 2650 RPM. No noticeable deficiencies were noted during the engine testing. The electric boost pump was tested at Mattituck. When activated the boost pump provided a continuous flow of fluid. ADDITIONAL INFORMATION FAA Regulation 91.205 states that small airplanes manufactured after July 18, 1978, must have an approved shoulder harness for each front seat. The original airworthiness certificate for N3804B was issued on July 26, 1956. N3804B was equipped with lap seat belts, but was not equipped with shoulder harnesses. The Bonanza Pilot's Operating Handbook (POH) states in the normal procedures section, under before starting, "Fuel Selector Valve - SELECT LEFT MAIN TANK." The other mention of fuel selection in the normal procedures section is in the Before Landing checklist, where it states, "Fuel Selector Valve - SELECT MAIN TANK MORE NEARLY FULL". According to the POH each of the main fuel tanks has a total capacity of 20 gallons, with 17 gallons of usable fuel in each. In the systems descriptions section of the POH it states, "takeoffs should be made using the left main tank...In no case should a takeoff be made if the fuel indicators are in the yellow band or, with less than 10 gallons of fuel in each main tank." The systems section also explains that the pressure type carburetor returns about 3 gallons per hour of excess fuel to the left main tank regardless of the tank selected. It further states, "To provide space for returned fuel, the left main cell should be used to approximately half full before switching." According to the POH, a typical fuel consumption for 2000 feet pressure altitude at 59 degrees fahrenheit would be 11.2 gallons-per-hour. Two takeoffs would use an additional 1 gallon of fuel. A total 1 hour fuel consumption would compute to about 12.2 gallons. The Bonanza POH states in the emergency procedure section under loss of power in flight, "...b. Fuel Quantity Indicator- CHECK (fuel tank being used is empty)." The wreckage was released, minus the engine and electric boost pump, on August 24, 1993, to John Cooley, a representative of the owners insurance company. The engine and boost pump were released on September 2, 1993, at the completion of the engine run.

Probable Cause and Findings

THE PILOT'S FAILURE TO SELECT A FUEL TANK THAT CONTAINED FUEL, AND PERFORM THE EMERGENCY PROCEDURE TO RESTART THE ENGINE, WHICH RESULTED IN FUEL STARVATION AND THE LOSS OF ENGINE POWER. FACTORS ARE THE PILOT'S LACK OF TOTAL EXPERIENCE AND HIS INADEQUATE INFLIGHT PLANNING.

 

Source: NTSB Aviation Accident Database

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