Beech E55 Baron, G-BFEE, 8 July 1996

Beech E55 Baron, G-BFEE, 8 July 1996 AAIB Bulletin No: 12/1996 Ref: EW/C96/7/13 Category: 1.2 Aircraft Type and Registration: Beech E55 Baron, G-BFEE No & Type of Engines: 2 Continental IO-520-C piston engines Year of Manufacture: 1973 Date & Time (UTC): 8 July 1996 at 1605 hrs Location: Trow Down, Berwick St. John, Wiltshire Type of Flight: Private Persons on Board: Crew - 1 - Passengers - 1 Injuries: Crew - Minor - Passengers - None Nature of Damage: Extensive Commander's Licence: Airline Transport Pilot's Licence with Flying Instructor Rating Commander's Age: 41 years Commander's Flying Experience: 2,275 hours (of which 27 were on type) Last 90 days - 60 hours Last 28 days - 40 hours Information Source: AAIB Field Investigation History of the flight At about 0815 hrs on the morning of 8 July, the operations departmentof a Bournemouth based airline was informed that one of theirjet aircraft was unserviceable in Dublin. It was ascertained thata spare part was required to be taken from Bournemouth to Dublin,along with an engineer to carry out the rectification task. The operations department telephoned an airport handling agencyin order to ascertain whether there was any locally based charteraircraft available to undertake the task. Telephone contact wasthen made with the operator of G-BFEE and a confirmation quotefor the flight was faxed by GBFEE's operator to the airlineoperations department. The airline's operations log indicatedthat the Baron aircraft was to be used, with an estimated departuretime of 1100 hrs and estimating to arrive in Dublin at 1230 hrs.The estimated time to accomplish the repair was one hour, andthe company's engineer required to return to Bournemouth in theafternoon of the same day. Meanwhile, the pilot involved in the accident had heard from thehandling agent's staff that there was a requirement for a flightto Dublin. The pilot then apparently telephoned G-BFEE's operatorand arranged to take the aircraft and operate the Dublin tripon a private basis. There was no direct contact between the pilotand the airline operations department. The airline operationsstaff considered that the flight was to be undertaken by an operatorholding, and in compliance with, a CAA Air Operator's Certificate. While the pilot obtained the appropriate navigation charts, checkedthe weather and filed the VFR flight plan for a direct routingto Dublin, G-BFEE's operator arranged for the aircraft to be refuelledto full tanks. The operator then taxied the aircraft around theairfield to pick up the engineer, the spare part and the engineer'stoolbox (which was stowed in the rear passenger area of the aircraft).The aircraft was then taxied back to its original parking locationto meet the pilot. After a wait of about 20 minutes, the pilotarrived at the aircraft. The engineer waited outside the aircraftwhile the operator and the pilot carried out a briefing sessionin the aircraft. The engineer considered that this briefing lastedabout ten minutes, but the pilot thought it was about one hourduration. Various systems were discussed including the GPS, flapsystem, landing gear, cowl flaps and the unconventional layoutof the throttle quadrant (described in AAIB Bulletin 2/96, G- BAHN). The fuel system on G-BFEE consisted of four fuel tanks, one main(37 USG capacity) and one auxiliary tank (31 USG capacity) ineach wing. Fuel quantity was measured by float type transmitterunits which conveyed signals to two indicators on the instrumentpanel (above the throttle quadrant). These indicated the amountof fuel in either the main tanks or the auxiliary tanks for theirrespective wings. A two position selector switch on the pilot'ssub-panel, to the left of the control console, determined thetanks, main or auxiliary, to which the indicators were connected.The pilot recalled being shown this switch during the pre-flightbriefing, but subsequent events indicated that the system operationwas not correctly understood. The fuel selectors were locatedon the floor between the two front seats, in a position not readilyobservable from the pilot's normal seating position. Four positionswere provided, OFF, AUX, MAIN and CROSS FEED for each side. The pilot commented that the operator seemed anxious to get theaircraft underway quickly and had completed the pre-flight inspectionearlier. The engineer reboarded, occupying the front right seat.He closed the door and was given a briefing on the emergency exitsby the pilot. The aircraft taxied out for a departure from Runway26. During the take-off roll, approaching lift-off speed, thedoor came open. The pilot abandoned the take off and brought theaircraft to a halt within the remaining runway distance. The aircraftwas then taxied round the airfield for a second take off attempt,while the engineer re-closed the door and ensured that it wasindeed correctly closed. The aircraft took off at 1138 hrs, landingat Dublin after an uneventful flight at 1302 hrs, a flight timeof one hour and 24 minutes. The pilot commented that the outboundflight had been conducted with the fuel gauge selector switchin the MAIN position. The engineer and pilot were transported across the Dublin Airportramp to the unserviceable aircraft. The engineer effected therepair, and the aircraft was recorded as being serviceable againat 1340 hrs. The engineer and pilot then had lunch at the airport.The pilot filed the return VFR flight plan to Bournemouth andthe weather was confirmed to be good for the route. G-BFEE tookoff again at 1452 hrs, still using the Main fuel tanks. The aircraft climbed to the selected cruise altitude of 5,000feet. The pilot then moved the fuel quantity indicator selectorswitch to the AUX position, under the misapprehension that thiswould transfer the fuel from the auxiliary tanks to the main tanks.The flight proceeded normally. As the aircraft crossed Wiltshire, the pilot descended to 3,000feet and began to reduce speed to 140 kt in anticipationof the arrival into Bournemouth. As the aircraft levelled off,the left engine began to run erratically, cutting out and thengiving surges of power. While attempting to control the aircraftdirectionally and analyse the problem, the right engine also failed.The aircraft had been turned towards Compton Abbas airfield asa possible landing site. Yeovilton Radar had been informed ofthe situation and the 7700 transponder code was activated. Thepilot realised that it would not be possible to reach ComptonAbbas and selected a flat field for a forced landing. However,on selecting the landing gear down, the glide angle steepenedsuch that it would not reach the chosen field. The aircraft wasapproaching rising ground cultivated with an arable crop. Thepilot selected full flap and stalled the aircraft onto the groundat about 1605 hrs on a southerly track. The impact was hard andthe aircraft stopped in about 20 metres. The pilot was wearing only a lap harness and sustained a minorhead injury on impact with the instrument panel. The engineerhad secured his full harness and sustained only minor bruisingwhere the harness had been positioned. The engineer pulled thepilot out of the aircraft. There was no fire, so the he returnedto the aircraft to pick up his mobile telephone and other itemsbefore calling for assistance. The emergency services had alreadybeen alerted by other witnesses to the accident. On inspection of the aircraft by the operator and his engineeringcontractor, it was discovered that the Main fuel tanks were completelyempty, but the Auxiliary tanks were still full. The engineer statedthat he did not recall the pilot operating the fuel tank selectorswitches on the floor of the aircraft at all during the two flights. Fuel Calculations The technical log sheets for the aircraft, in conjunction withrefuelling and movement information over a period of a few daysbefore the accident, were examined in order to assess the aver

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Beech E55 Baron, G-BFEE, 8 July 1996

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