AOPA Pilot Magazine - February 2021 - 81

The fuel gauges become a dominant part of the instrument scan;
watching, willing them to stop
dropping. It's difficult to stay
in the moment and not second
guess the decision. Your present
self is agitated with what it must
now contend with, because of the
flawed logic of your past self-
and your future self butting in,
asking how you will ever explain
such a poor decision.
In those last few minutes,
the pilot understood his issue
was fuel exhaustion, but he
would have been confused. He
used an engine data monitor to
track 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 12 gallons less fuel
for the last five 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.
In dense weather, 13 miles
from his destination at about
2,000 feet agl, both engines sputtered and quit within 10 seconds
of each other. The pilot deadsticked the Baron for 40 seconds,
sinking rapidly before somehow
routing fuel to restart the left
engine. Continuing inbound on
the approach, he broke out below
the overcast at 500 feet agl, near
course guidance, but well below

approach profile altitudes and
in a descent he couldn't arrest.
Using full power on the left
engine he raised the nose further,
still further in a futile attempt to
stop the descent.
A single-engine Baron near
maximum gross weight will
not hold level flight with flaps
extended and an unfeathered
propeller. Sinking to 300 feet
agl, the airspeed fell below 83
knots, VMC in a Beech 58 Baron-
an ominous threshold for all twin
aircraft. The airplane began rolling to the right, which no amount
of rudder or aileron could avert.
The aircraft crashed flat, wings
almost level, indicating the pilot
flew the Baron through the VMC
roll, fighting to the end to minimize the force of impact.
The accident sequence started
with a misunderstanding of the
actual fuel state, eight days before
the accident. The ultimate irony
is that the decision on the mishap
flight to operate just four gallons
shy of legal requirements proved
catastrophic.
Four gallons wouldn't normally matter, but on this flight,
four gallons would have been
enough to keep both engines
operating for 13 more miles, thus
precluding the final sequence of
events and mortal configuration
errors-the same four gallons the
pilot seemed to believe was just a
technical requirement and not a
practical one. Fate has a morbid
sense of irony. 
AOPA
airsafetyinstitute.org
EMAIL richard.mcspadden@aopa.

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AOPA Pilot Magazine - February 2021

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