It’s April 22nd, 2019. In the early morning
light at West Houston Airport in Texas, the pilot of a Beechcraft Baron 58
performs an abbreviated preflight inspection of his aircraft, before heading
to the terminal to greet his passengers. Their destination is Kerrville Municipal
Airport, 178 nautical miles to the west. The flight will take just over one hour.
The 5,600-hour pilot is ATP-rated, with 2,400 hours of Baron time. He is planning a departure
with what he believes to be 54 usable gallons of fuel on board. According to the pilot’s IFR flight
plan, he estimates the trip to Kerrville will legally require 58 gallons, including reserves,
but will only consume about 38 gallons in total. The pilot knows he is 4 gallons short of
the legal requirement, which states that he must have 45 minutes of reserve fuel
on board. Under different circumstances, the pilot would likely add more fuel, but taking
on more fuel would mean a heavier load. With five passengers and his expected fuel onboard, the
Baron is already slightly over its maximum gross weight. To make matters worse, the airplane’s
center of gravity is slightly aft of limits. Although his current fuel plan
leaves little margin for error, the pilot believes he will have
sufficient fuel to fly the trip. However, there’s another problem – a
discrepancy that has gone undetected over the last several days. The aircraft is not
carrying as much fuel as the pilot expects. The pilot relies on an engine data monitoring
system to accurately track fuel consumption, but it requires the correct manual inputs
after each refueling to update total fuel. He also keeps a manual fuel log in the airplane,
and he is meticulous in updating it after each flight. However, both of these methods require
manual inputs from the pilot. Neither can assess the actual fuel quantity in the airplane.
NTSB investigators believe the pilot’s actual fuel level was below his expected level for eight
days, and five flights prior to today’s flight. The Baron’s wing tanks only have tabs that
indicate 40 and 60 gallons. Unless the tanks are at either of those quantities, actual fuel
quantity can only be roughly estimated by visual inspection. The fuel levels for this flight are
now well below the 40-gallon tab on each wing. The pilot loads up his five passengers, and
carrying only 42 gallons of usable fuel for a planned one hour and eight minute flight,
departs West Houston Airport around 7:30am. It’s now 8:24am, and the Baron is 35 nautical
miles from Kerrville Municipal Airport, which currently sits under an overcast cloud layer
at 1,200 feet. The weather conditions at Kerrville are worse than forecast, and the pilot is unable
to fly a visual approach directly to the airport. He asks ATC for the GPS approach to runway 12, and the controller clears him
direct to the waypoint OBUCO. This waypoint, unfortunately, is 12.5 nautical
miles beyond the airport, to the northwest. This will mean more time spent in
the air, and additional fuel burn. 20 minutes later, the Baron has flown a path
to intercept the GPS approach to runway 12, and is inbound to the airport on a southeast
heading. Thirteen miles from the airport, at about 2,000 feet AGL, both engines sputter
and quit within 10 seconds of each other. For the next 40 seconds, the pilot keeps the Baron
under controlled descent, losing altitude rapidly while working to restart the engines. Somehow, he
is able to route fuel to restart the left engine. However, the pilot doesn’t retract the flaps, and
he does not feather the inoperative right engine, which goes against the guidance of the
airplane manufacturer’s emergency procedures. Feathering a propeller of a dead
engine significantly reduces drag, which would have helped to
arrest his descent rate. Continuing inbound on the approach, the Baron
breaks out below the overcast at 500 feet AGL. The pilot has kept the airplane
near the approach course guidance, but he is well below approach altitudes. The pilot
raises the nose in an attempt to stop his descent. A single-engine Baron near maximum gross weight
and aft of CG limits will not hold level flight with flaps extended and an unfeathered
propeller. Sinking to 300 feet AGL, the airspeed falls below 83 knots, which is the minimum
controllable airspeed, or VMC, of the Baron. The airplane begins rolling to the right, which
no amount of rudder or aileron can counteract. The Baron crashes flat, wings almost
level, indicating the pilot flew the airplane through the VMC roll, fighting to
the end to minimize the force of impact. All six aboard are killed. In those last few minutes, the pilot likely
understood his issue was fuel exhaustion, but he would have been confused. His engine data monitor
tracked fuel consumption, which aligned with his manual log, both of which led him to infer he was
low but had fuel to make it. His fuel gauges also indicated fuel remaining. He didn’t know he’d been
carrying less fuel, perhaps for the last several flights. And he didn’t know his fuel gauges were
lying to him in the worst possible way, indicating more fuel than there actually was. The NTSB would
discover that excessive resistance in the fuel tank transmitters caused a surplus fuel reading
of approximately five gallons in each wing tank. On the ramp at West Houston Airport, the pilot
likely knew he was pushing the weight limits of the Baron. In considering his fuel status, he
was managing a dilemma almost all GA pilots have faced. He knew his fuel state was tight, but
likely believed the risk of adding more weight was greater than the risk of fuel exhaustion.
Neglecting to take on additional fuel also left the pilot with little room for contingencies.
His plan was crafted with no room for variation, but the instrumentation in his Baron didn’t allow
for such precise measurement. Weather, winds, ATC routing and other uncontrollable factors
would all need to work in his favor in order to fly a straight-line route to Kerrville.
Ultimately, it didn’t turn out this way. Pilots who have pushed fuel limits can attest
to the sinking feeling as seconds grind by. The fuel gauges become a dominant
part of the instrument scan; watching, willing them to stop dropping. Any unexpected
deviation in routing makes matters worse. The final chance to avert disaster came after
the pilot managed to restart the left engine. Had he taken the appropriate actions, the
outcome might have been a single-engine landing at Kerrville Airport or an emergency landing off
field in relatively flat terrain. But the pilot allowed excessive drag by his failure to retract
flaps and feather the dead engine. It was this oversight that caused the Baron to slow beyond the
critical VMC airspeed and ultimately lose control. Although the pilot was highly experienced,
inaccurate fuel calculations and the stress of the situation, which led to deficiencies in emergency
response, proved to be a fatal mixture. When an emergency occurs and does not leave time to pull
out a checklist, a pilot’s immediate and practiced response is critical. There is no substitute
for repeated practice in this area. Perhaps the pilot would have benefitted from more frequent and
focused training on critical emergency response. The ultimate irony is that the decision on the
accident flight to operate just four gallons shy of legal requirements proved catastrophic.
Four gallons wouldn’t normally matter in a Baron, but on this flight, four gallons would
have been enough to keep both engines operating for 13 more miles - the same four
gallons the pilot seemed to believe was just a technical requirement and not a practical one.
When flying GA, we must plan our flights within the accuracy of our equipment, particularly for
fuel. We should always include enough reserve fuel to allow for equipment variation, mistakes, and
contingencies. Most pilots have faced the dilemma of more fuel versus more payload. This tragedy
illustrates the consequences of misprioritizing that calculation, of cutting corners and relying
on equipment beyond the designs of its accuracy. Thanks for watching this video. The Air
Safety Institute is part of the Aircraft Owners and Pilots Association. If you'd like
to see more of these videos and support us, join AOPA now at aopa.org.
Another humbling case study from the ASI. I've seen many people depart after saying Eh, it'll be fine. This is a great video to show that things can quickly turn to catastrophe.
Instead of turning the discussion towards the topic of the video, I'll satisfy rule three by asking if there are any GA accidents you know of that you think would be a good subject for a future ASI Case Study.
One area this video touches on, but that I want to highlight especially to us in GA flying IFR: we don't file instrument approaches, but we sure as shit need to plan for them. When I do my navlogs on ForeFlight or FltPlan, I draw the route to include the worst-case/opposite direction instrument approach. Sometimes that's an additional 30 miles.
Same with missed approaches. Scary accident. Great video.
As a baron 58 owner operator who has flown west Houston to kerville before, this video makes me so frustrated.
This experienced pilot killed 4 other people because he thought he knew better. Even though kerville is the foothills of “hill country” there are so many good landing options. Owning a twin complicated this whole thing as he clearly wasn’t thinking about ditching the plane. Might as well just put the gear down for the full trifecta effect. Awful, frustrating, and completely avoidable.
Excellent case study
I love these videos, I talked with an AOPA representative at Sun N Fun about them and how much they help me as a student pilot learn from others mistakes, and some of them are not what you would first think.
Example, the NEXRAD one in Texas, I never knew NEXRAD was 10 - 15 minutes old due to the interpolation rate, completely changed my perception of NEXRAD from "oh this counts as cheap weather RADAR" to "this is a weather ADVISORY system", two entirely different things and mistaking the two can be fatal as that video showcased.