Fuel exhaustion Accident Beechcraft 58 Baron ZS-MCY, Thursday 10 October 2024
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Date:Thursday 10 October 2024
Time:15:17 UTC
Type:Silhouette image of generic BE58 model; specific model in this crash may look slightly different    
Beechcraft 58 Baron
Owner/operator:
Registration: ZS-MCY
MSN: TH-764
Fatalities:Fatalities: 0 / Occupants: 1
Other fatalities:0
Aircraft damage: Substantial
Category:Accident
Location:N5 Road between Senekal and Winburg, Free State Province -   South Africa
Phase: En route
Nature:Private
Departure airport:Bethlehem (FABM)
Destination airport:Bloemfontein/New Tempe (FATP)
Investigating agency: CAA S.A.
Confidence Rating: Accident investigation report completed and information captured
Narrative:
A pilot on-board a Beech 58 aircraft with registration ZS-MCY took off on a private flight from Bethlehem Aerodrome (FABM) to New Tempe Aerodrome (FATP) near Bloemfontein in the Free State province.

The pilot, a specialised surgeon, had planned to attend to patients in Mbombela and Bethlehem before he could return to Bloemfontein in his four-day trip. At the pilot's request, the aircraft was prepared by the aircraft maintenance organisation (AMO) based at FATP. On Monday morning, 7 October 2024, the aircraft was parked at the apron. The pilot, who is part-owner of the aircraft, stated that during his pre-flight inspection he checked the external fuel level sight gauges that are located on each wing (see Figure 6). He later took off from FATP to Nelspruit Aerodrome (FANS), the duration of this flight was 2 hours and 12 minutes (2.2 hours). The aircraft was then parked at FANS until Thursday morning, 10 October 2024. Early on Thursday morning, the pilot flew from FANS to Bethlehem Aerodrome (FABM) where he consulted during the day. This flight was also 2 hours and 12 minutes (2.2 hours). At approximately 1454Z that afternoon, the pilot took off from FABM to FATP.

The pilot stated that approximately 20 minutes after take-off from FABM, one of the engines started to splutter and, thereafter, stopped. The pilot then checked the fuel gauges on the instrument panel, and both indicated empty. During an interview with the investigator, the pilot made the following statement about the fuel gauges: 'These gauges always under-read by as much as half a tank, so I always relied upon the outside (wing) gauges when preparing for flights. These outside gauges are tricky to read through the Perspex or glass coverings, especially when there is sunlight glare and even more so when stressed and, in a hurry, and under the false impression that the tanks are as
full as expected. Furthermore, due to the extra-large tanks, the centrally mounted, 360° needles point in the same direction when the tanks are either empty or full. Also, the needles have two ends, a sharp end that should be used, and a diametrically opposite blunt end that should be ignored.'
The pilot further stated that he realised that the aircraft was out of fuel and that the second engine would also stop. Therefore, he declared an emergency with Johannesburg Central. At this time, he had identified a useful, long straight stretch of the National Road (N) 5 between Senekal and Winburg. As he approached the road, he performed a 360° turn to the left and then touched down as there were no vehicles on the road in his immediate vicinity. The road was approximately 12 metres (m) wide and comprised three lanes and a shoulder on each side. Before touching down, he switched off the master switch and the magnetos and tried to turn the fuel selectors to the OFF position. During the landing roll, which was upslope, the aircraft veered to the left of the road. The left-wing tip struck several safety hazard (chevron) boards next to the road and impacted a stormwater barrier which caused the aircraft to yaw violently. The aircraft came to rest on the left side of the road and faced towards the road. According to the pilot, the landing gear did not extend when he selected it to the DOWN position. There were no skid markings of the lower fuselage on the surface of the road that would indicate that the landing gear did not extend. The landing gear lever was found in the DOWN position. The pilot had bruises after the accident; the aircraft was substantially damaged.

Probable Cause
Following a dual engine stoppage in-flight due to fuel exhaustion, the pilot landed the aircraft on a National Road (N5) and lost directional control which resulted in the left wing striking several road hazard markers next to the road as well as a stormwater barrier. The aircraft came to rest in a trench next to the road

Contributing Factors
1. The pilot displayed a total disregard for standard safe operating procedures.
2. The pilot neglected to perform a proper pre-flight inspection before departure from FATP, which included ensuring the aircraft was refuelled to capacity (he did not open the fuel tank filler caps to physically inspect the fuel level).
3. The pilot neglected to perform a proper pre-flight inspection before departure from FABM.
4. The pilot failed to conduct proper flight planning.

Accident investigation:
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Investigating agency: CAA S.A.
Report number: CA18/2/3/10514
Status: Investigation completed
Duration: 4 months
Download report: Final report

Sources:

SACAA

Location

Revision history:

Date/timeContributorUpdates
14-Feb-2025 15:09 ASN Added
14-Feb-2025 15:12 ASN Updated [Aircraft type, Cn, Location, Phase, Departure airport, Destination airport, Narrative, ]

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