On April 22, 2019, a Beech 58 was substantially damaged when it was involved in an accident near Kerrville Municipal Airport (KERV) in Texas. The pilot and five passengers died.
According to airport surveillance video from West Houston Airport (KIWS), the pilot did an abbreviated preflight inspection of the airplane, during which he appeared to visually check the exterior left-wing fuel level sight gauge, but not the right-wing fuel level sight gauge. He did not sump any of the 10 fuel drains.
According to air traffic control (ATC) and automatic dependent surveillance-broadcast (ADS-B) information, after departing KIWS about 7:30 a.m., the pilot obtained an instrument flight rules (IFR) clearance and was instructed to climb to 3,000 feet mean sea level (msl). The flight proceeded toward KERV, climbing to a cruise altitude of 6,000 feet msl.
About 8:24, he requested the RNAV (GPS) instrument approach for Runway 12 and was cleared for the approach via a procedure turn and to descend to 4,000 feet. About 8:33, he reported his descent to 4,000 feet and the controller advised that “bases were 2,400,” which the pilot acknowledged.
At 8:39, the pilot was cleared for the GPS instrument approach to Runway 12 and instructed to maintain 4,000 feet to the initial fix for the approach. Once the airplane was in-bound to the airport, at about 8:43, the controller directed the pilot to switch to the KERV advisory frequency, which was unmonitored. The GPS instrument approach profile for Runway 12 included a descent to 3,300 feet msl at 5.3 nautical miles from the runway.
According to ADS-B data, the airplane maintained an altitude of 3,900 feet until about 8:45, when it began a steady descent. The plane was about 13 miles from the runway.
Data from the airplane’s engine data monitor (EDM) indicate that the left engine lost power at about 8:45, followed by the right engine about 10 seconds later. ADS-B data indicated that the airplane steadily descended well below the approach profile.
EDM data indicated that, about 40 seconds after losing power, the left engine regained near full power, which it maintained until the end of recorded EDM data at 8:51. According to ADS-B data, the plane slowed below the minimum controllable airspeed (Vmc) of 83 knots as it descended from about 500 to 300 feet agl, and the descent rate decreased.
A witness on the ground saw the plane on final approach at a low altitude, when it entered a right turn, began a right spiral, and disappeared behind a ridge line.
The airplane hit a rocky ravine about 120 yards from the final radar data point and about six miles from the airport. There was no post-impact fire and the airplane came to rest upright on a heading of 246°. The wreckage was contained within the footprint of the airplane, indicating a low forward groundspeed. Elevation at the accident site was 1,868 feet msl and trees about 40 yards northeast were the nearest obstructions.
All flight control surfaces were present and flight control cable continuity was established from the tail surfaces to the aft empennage, where the cables were bound by the cabin floor, which was crushed by impact forces. Aileron and aileron trim tab cable continuity was established from the control surface to the wing root.
About one gallon of fuel was drained from the left-wing fuel cells on the day of the accident. When the left wing was lifted at the wing tip on the day after the accident, about one cup of fuel was observed in the left-wing fuel cells and about one cup of fuel drained from a breached area near the engine nacelle. No fuel was observed in the right-wing wet tip tank or the right-wing fuel cells. All fuel tank caps were secured.
The left fuel selector was near the ON position; it was positioned about 1/4 toward OFF. A small amount of fuel was found in the left fuel selector valve and fuel strainer. The right fuel selector was in the ON position. No fuel was present in the right fuel selector valve or fuel strainer. No water was detected.
Both engines were examined, and no anomalies were observed that would have prevented normal operation.
Probable Cause: The pilot’s inadequate preflight fuel planning and fuel management, which resulted in a loss of engine power due to fuel exhaustion. Also causal was the pilot’s failure to follow the one-engine inoperative checklist and maintain the airplane’s minimum controllable airspeed by properly configuring the airplane, which resulted in a loss of airplane controllability.
Many pilots fall prey to “magical thinking!” The numbers here just do not add up; too many pax and not enough fuel. Physics is always unforgiving; you cannot “stretch fuel!”
This April 2019 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.
