It’s April 22nd, 2019. In the early morningÂ
light at West Houston Airport in Texas,  the pilot of a Beechcraft Baron 58Â
performs an abbreviated preflight  inspection of his aircraft, before headingÂ
to the terminal to greet his passengers. Their destination is Kerrville MunicipalÂ
Airport, 178 nautical miles to the west.  The flight will take just over one hour.
The 5,600-hour pilot is ATP-rated, with 2,400Â Â hours of Baron time. He is planning a departureÂ
with what he believes to be 54 usable gallons of  fuel on board. According to the pilot’s IFR flightÂ
plan, he estimates the trip to Kerrville will  legally require 58 gallons, including reserves,Â
but will only consume about 38 gallons in total. The pilot knows he is 4 gallons short ofÂ
the legal requirement, which states that  he must have 45 minutes of reserve fuelÂ
on board. Under different circumstances,  the pilot would likely add more fuel, but takingÂ
on more fuel would mean a heavier load. With five  passengers and his expected fuel onboard, theÂ
Baron is already slightly over its maximum gross  weight. To make matters worse, the airplane’sÂ
center of gravity is slightly aft of limits. Although his current fuel planÂ
leaves little margin for error,  the pilot believes he will haveÂ
sufficient fuel to fly the trip. However, there’s another problem – aÂ
discrepancy that has gone undetected over  the last several days. The aircraft is notÂ
carrying as much fuel as the pilot expects. The pilot relies on an engine data monitoringÂ
system to accurately track fuel consumption,  but it requires the correct manual inputsÂ
after each refueling to update total fuel.  He also keeps a manual fuel log in the airplane,Â
and he is meticulous in updating it after each  flight. However, both of these methods requireÂ
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 eightÂ
days, and five flights prior to today’s flight. The Baron’s wing tanks only have tabs thatÂ
indicate 40 and 60 gallons. Unless the tanks  are at either of those quantities, actual fuelÂ
quantity can only be roughly estimated by visual  inspection. The fuel levels for this flight areÂ
now well below the 40-gallon tab on each wing. The pilot loads up his five passengers, andÂ
carrying only 42 gallons of usable fuel for  a planned one hour and eight minute flight,Â
departs West Houston Airport around 7:30am. It’s now 8:24am, and the Baron is 35 nauticalÂ
miles from Kerrville Municipal Airport,  which currently sits under an overcast cloud layerÂ
at 1,200 feet. The weather conditions at Kerrville  are worse than forecast, and the pilot is unableÂ
to fly a visual approach directly to the airport.  He asks ATC for the GPS approach to runway 12,  and the controller clears himÂ
direct to the waypoint OBUCO. This waypoint, unfortunately, is 12.5 nauticalÂ
miles beyond the airport, to the northwest.  This will mean more time spent inÂ
the air, and additional fuel burn. 20 minutes later, the Baron has flown a pathÂ
to intercept the GPS approach to runway 12,  and is inbound to the airport on a southeastÂ
heading. Thirteen miles from the airport,  at about 2,000 feet AGL, both engines sputterÂ
and quit within 10 seconds of each other. For the next 40 seconds, the pilot keeps the BaronÂ
under controlled descent, losing altitude rapidly  while working to restart the engines. Somehow, heÂ
is able to route fuel to restart the left engine.  However, the pilot doesn’t retract the flaps, andÂ
he does not feather the inoperative right engine,  which goes against the guidance of theÂ
airplane manufacturer’s emergency procedures.  Feathering a propeller of a deadÂ
engine significantly reduces drag,  which would have helped toÂ
arrest his descent rate. Continuing inbound on the approach, the BaronÂ
breaks out below the overcast at 500 feet AGL.  The pilot has kept the airplaneÂ
near the approach course guidance,  but he is well below approach altitudes. The pilotÂ
raises the nose in an attempt to stop his descent. A single-engine Baron near maximum gross weightÂ
and aft of CG limits will not hold level flight  with flaps extended and an unfeatheredÂ
propeller. Sinking to 300 feet AGL, the airspeed  falls below 83 knots, which is the minimumÂ
controllable airspeed, or VMC, of the Baron. The airplane begins rolling to the right, whichÂ
no amount of rudder or aileron can counteract.  The Baron crashes flat, wings almostÂ
level, indicating the pilot flew the  airplane through the VMC roll, fighting toÂ
the end to minimize the force of impact. All six aboard are killed. In those last few minutes, the pilot likelyÂ
understood his issue was fuel exhaustion, but he  would have been confused. His engine data monitorÂ
tracked fuel consumption, which aligned with his  manual log, both of which led him to infer he wasÂ
low but had fuel to make it. His fuel gauges also  indicated fuel remaining. He didn’t know he’d beenÂ
carrying less fuel, perhaps for the last several  flights. And he didn’t know his fuel gauges wereÂ
lying to him in the worst possible way, indicating  more fuel than there actually was. The NTSB wouldÂ
discover that excessive resistance in the fuel  tank transmitters caused a surplus fuel readingÂ
of approximately five gallons in each wing tank. On the ramp at West Houston Airport, the pilotÂ
likely knew he was pushing the weight limits  of the Baron. In considering his fuel status, heÂ
was managing a dilemma almost all GA pilots have  faced. He knew his fuel state was tight, butÂ
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.Â
His plan was crafted with no room for variation,  but the instrumentation in his Baron didn’t allowÂ
for such precise measurement. Weather, winds,  ATC routing and other uncontrollable factorsÂ
would all need to work in his favor in order  to fly a straight-line route to Kerrville.Â
Ultimately, it didn’t turn out this way. Pilots who have pushed fuel limits can attestÂ
to the sinking feeling as seconds grind by.  The fuel gauges become a dominantÂ
part of the instrument scan; watching,  willing them to stop dropping. Any unexpectedÂ
deviation in routing makes matters worse. The final chance to avert disaster came afterÂ
the pilot managed to restart the left engine.  Had he taken the appropriate actions, theÂ
outcome might have been a single-engine landing  at Kerrville Airport or an emergency landing offÂ
field in relatively flat terrain. But the pilot  allowed excessive drag by his failure to retractÂ
flaps and feather the dead engine. It was this  oversight that caused the Baron to slow beyond theÂ
critical VMC airspeed and ultimately lose control. Although the pilot was highly experienced,Â
inaccurate fuel calculations and the stress of the  situation, which led to deficiencies in emergencyÂ
response, proved to be a fatal mixture. When an  emergency occurs and does not leave time to pullÂ
out a checklist, a pilot’s immediate and practiced  response is critical. There is no substituteÂ
for repeated practice in this area. Perhaps the  pilot would have benefitted from more frequent andÂ
focused training on critical emergency response. The ultimate irony is that the decision on theÂ
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 wouldÂ
have been enough to keep both engines  operating for 13 more miles - the same fourÂ
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 forÂ
fuel. We should always include enough reserve fuel  to allow for equipment variation, mistakes, andÂ
contingencies. Most pilots have faced the dilemma  of more fuel versus more payload. This tragedyÂ
illustrates the consequences of misprioritizing  that calculation, of cutting corners and relyingÂ
on equipment beyond the designs of its accuracy. Thanks for watching this video. The AirÂ
Safety Institute is part of the Aircraft  Owners and Pilots Association. If you'd likeÂ
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.