AOPA Pilot Magazine - February 2021 - 80

summoned
all his experience to redirect fate
in a battle he was losing. Heavy
weight, with center of gravity
aft of limits, and eyeing his fuel
gauges, he was descending on
the GPS approach, in instrument
meteorological conditions, when
he lost power on both engines 13
miles from the field. Amid the
confusion and a daunting workload, he restored one engine, but
didn't feather the propeller on
the dead engine and left the flaps
extended. According to the NTSB
investigation, that was the last in
a series of mistakes and misjudgments that would cost the pilot
and five passengers their lives.
The aircraft was a Beechcraft
Baron 58. According to the NTSB,
THE ATP-RATED PILOT

inputs after each refueling to
update total fuel.
The only way to confirm a
full top-off in a Beech 58 is to
open each main wing and tip
tank fuel cap and visually check
the fuel status. There was no
cockpit indication to the pilot
that his actual fuel state was
12 gallons less than full. The
aberration lay dormant for five
uneventful flights.
Video surveillance confirmed
the pilot visually checked the
left-wing tank quantity before
the mishap flight; however, the
Baron wing tanks only have tabs

At maximum gross weight, he knew his
fuel state was tight, leaving little margin for
contingencies. It's likely he believed the risk of
adding more weight was greater than the
risk of fuel exhaustion.
the tragic sequence began when
the 5,600-hour pilot (with 2,400
hours Baron time) believed he
had refueled to full capacity
several days before the mishap
flight. In actuality, investigators
believe, he was approximately
12 gallons short of his expectation. Tip tanks on a Beech 58 can
be partially refueled through the
main wing filler port, but a full
top-off requires pumping the last
six gallons directly through the
fueling port of each tip tank. Left
and right fuel gauges on a Beech
Baron 58 register full once the
tanks are above 75 gallons and
stay at that full reading until fuel
falls below that level. The engine
data monitoring system the pilot
used accurately tracked fuel consumption, but it required manual
80 | AOPA PILOT February 2021

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 pilot was planning a departure with what he believed was
54 total usable gallons. Fuel levels would have been well below
the 40-gallon tab on each wing,
so a visual inspection provided
no insight. He seemed to accept
this by not bothering to check the
right fuel tank.
The pilot's manual fuel and
flight time log indicated he
thought his fuel state to be 54
usable gallons at engine start
of the mishap flight. According
to his ForeFlight flight plan,
he believed his trip from West
Ho u st o n A i r p o r t ( I WS ) t o

Kerrville Municipal Airport/
Louis Schreiner Field (ERV)
legally required 58 gallons,
including reserves, but would
only require 38 gallons to fly.
Based on NTSB reports, the pilot
knew he was fudging his reserve
requirement by four gallons but
thought he would have sufficient
fuel to fly the trip. What difference is four gallons when you're
burning 28 gallons per hour?
The pilot was managing a
dilemma almost all GA pilots
have faced. He likely would have
preferred more fuel, but taking
on more fuel would exacerbate
his gross weight problem. He
was already at, perhaps slightly
above, the Baron's limitations.
At maximum gross weight, he
knew his fuel state was tight,
leaving little margin for contingencies. It's likely that he
believed the risk of adding more
weight was greater than the risk
of fuel exhaustion. That riskmanagement calculation would
have succeeded except for the
hidden problem, still beyond his
recognition, that he didn't have
enough usable fuel to fly the trip.
The actual usable fuel state
at departure was close to 42 gallons and the Baron consumed
it all. Weather worse than forecast precluded vectors to a visual
approach, which the pilot likely
expected. Instead, he was forced
to fly beyond the airport and
shoot an approach back into
Kerrville, using more fuel than
he planned, but less than what
he thought was on board.
Pilots who have pushed fuel
limits can attest to the sinking feeling as seconds grind by.



AOPA Pilot Magazine - February 2021

Table of Contents for the Digital Edition of AOPA Pilot Magazine - February 2021

Contents
AOPA Pilot Magazine - February 2021 - Intro
AOPA Pilot Magazine - February 2021 - Cover1
AOPA Pilot Magazine - February 2021 - Cover2
AOPA Pilot Magazine - February 2021 - Contents
AOPA Pilot Magazine - February 2021 - 2
AOPA Pilot Magazine - February 2021 - 3
AOPA Pilot Magazine - February 2021 - 4
AOPA Pilot Magazine - February 2021 - 5
AOPA Pilot Magazine - February 2021 - 6
AOPA Pilot Magazine - February 2021 - 7
AOPA Pilot Magazine - February 2021 - 8
AOPA Pilot Magazine - February 2021 - 9
AOPA Pilot Magazine - February 2021 - 10
AOPA Pilot Magazine - February 2021 - 11
AOPA Pilot Magazine - February 2021 - 12
AOPA Pilot Magazine - February 2021 - 13
AOPA Pilot Magazine - February 2021 - 14
AOPA Pilot Magazine - February 2021 - 15
AOPA Pilot Magazine - February 2021 - 16
AOPA Pilot Magazine - February 2021 - 17
AOPA Pilot Magazine - February 2021 - 18
AOPA Pilot Magazine - February 2021 - 19
AOPA Pilot Magazine - February 2021 - 20
AOPA Pilot Magazine - February 2021 - 21
AOPA Pilot Magazine - February 2021 - 22
AOPA Pilot Magazine - February 2021 - 23
AOPA Pilot Magazine - February 2021 - 24
AOPA Pilot Magazine - February 2021 - 25
AOPA Pilot Magazine - February 2021 - 26
AOPA Pilot Magazine - February 2021 - 27
AOPA Pilot Magazine - February 2021 - 28
AOPA Pilot Magazine - February 2021 - 29
AOPA Pilot Magazine - February 2021 - 30
AOPA Pilot Magazine - February 2021 - 31
AOPA Pilot Magazine - February 2021 - 32
AOPA Pilot Magazine - February 2021 - 33
AOPA Pilot Magazine - February 2021 - 34
AOPA Pilot Magazine - February 2021 - 35
AOPA Pilot Magazine - February 2021 - 36
AOPA Pilot Magazine - February 2021 - 37
AOPA Pilot Magazine - February 2021 - 38
AOPA Pilot Magazine - February 2021 - 39
AOPA Pilot Magazine - February 2021 - 40
AOPA Pilot Magazine - February 2021 - 41
AOPA Pilot Magazine - February 2021 - 42
AOPA Pilot Magazine - February 2021 - 43
AOPA Pilot Magazine - February 2021 - 44
AOPA Pilot Magazine - February 2021 - 45
AOPA Pilot Magazine - February 2021 - 46
AOPA Pilot Magazine - February 2021 - 47
AOPA Pilot Magazine - February 2021 - 48
AOPA Pilot Magazine - February 2021 - 49
AOPA Pilot Magazine - February 2021 - 50
AOPA Pilot Magazine - February 2021 - 51
AOPA Pilot Magazine - February 2021 - 52
AOPA Pilot Magazine - February 2021 - 53
AOPA Pilot Magazine - February 2021 - 54
AOPA Pilot Magazine - February 2021 - 55
AOPA Pilot Magazine - February 2021 - 56
AOPA Pilot Magazine - February 2021 - 57
AOPA Pilot Magazine - February 2021 - 58
AOPA Pilot Magazine - February 2021 - 59
AOPA Pilot Magazine - February 2021 - 60
AOPA Pilot Magazine - February 2021 - 61
AOPA Pilot Magazine - February 2021 - 62
AOPA Pilot Magazine - February 2021 - 63
AOPA Pilot Magazine - February 2021 - 64
AOPA Pilot Magazine - February 2021 - 65
AOPA Pilot Magazine - February 2021 - 66
AOPA Pilot Magazine - February 2021 - 67
AOPA Pilot Magazine - February 2021 - 68
AOPA Pilot Magazine - February 2021 - 69
AOPA Pilot Magazine - February 2021 - 70
AOPA Pilot Magazine - February 2021 - 71
AOPA Pilot Magazine - February 2021 - 72
AOPA Pilot Magazine - February 2021 - 73
AOPA Pilot Magazine - February 2021 - 74
AOPA Pilot Magazine - February 2021 - 75
AOPA Pilot Magazine - February 2021 - 76
AOPA Pilot Magazine - February 2021 - 77
AOPA Pilot Magazine - February 2021 - 78
AOPA Pilot Magazine - February 2021 - 79
AOPA Pilot Magazine - February 2021 - 80
AOPA Pilot Magazine - February 2021 - 81
AOPA Pilot Magazine - February 2021 - 82
AOPA Pilot Magazine - February 2021 - 83
AOPA Pilot Magazine - February 2021 - 84
AOPA Pilot Magazine - February 2021 - 85
AOPA Pilot Magazine - February 2021 - 86
AOPA Pilot Magazine - February 2021 - 87
AOPA Pilot Magazine - February 2021 - 88
AOPA Pilot Magazine - February 2021 - 89
AOPA Pilot Magazine - February 2021 - 90
AOPA Pilot Magazine - February 2021 - 91
AOPA Pilot Magazine - February 2021 - 92
AOPA Pilot Magazine - February 2021 - 93
AOPA Pilot Magazine - February 2021 - 94
AOPA Pilot Magazine - February 2021 - 95
AOPA Pilot Magazine - February 2021 - 96
AOPA Pilot Magazine - February 2021 - 97
AOPA Pilot Magazine - February 2021 - 98
AOPA Pilot Magazine - February 2021 - 99
AOPA Pilot Magazine - February 2021 - 100
AOPA Pilot Magazine - February 2021 - 101
AOPA Pilot Magazine - February 2021 - 102
AOPA Pilot Magazine - February 2021 - 103
AOPA Pilot Magazine - February 2021 - 104
AOPA Pilot Magazine - February 2021 - 105
AOPA Pilot Magazine - February 2021 - 106
AOPA Pilot Magazine - February 2021 - 107
AOPA Pilot Magazine - February 2021 - 108
AOPA Pilot Magazine - February 2021 - 109
AOPA Pilot Magazine - February 2021 - 110
AOPA Pilot Magazine - February 2021 - 111
AOPA Pilot Magazine - February 2021 - 112
AOPA Pilot Magazine - February 2021 - Cover3
AOPA Pilot Magazine - February 2021 - Cover4
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