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Accidents · NTSB WPR11FA125 · Final report

Beech 95-B55 (T42A) accident near San Bernardino, California, February 7, 2011

On February 7, 2011 at about 7:47 pm local time, a Beech 95-B55 (T42A), registered N225DH, was substantially damaged in an accident during approach (VFR go-around) near San Bernardino, California (San Bernardino International airport). It was a personal flight under general aviation rules (Part 91). 2 people were seriously injured. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The pilot did not recognize the loss of power in the right engine and did not execute the proper procedures for a go-around with one engine inoperative, likely due to increased workload. Contributing to the accident was the pilot's improper in-flight fuel management, which resulted in fuel starvation of the right engine.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
February 7, 2011 · about 7:47 pm local time
Place
San Bernardino, California · San Bernardino International · map
Type
Accident
Injuries
2 people were seriously injured.
Weather
visual conditions (good weather)
Aircraft
Beech 95-B55 (T42A) · all 95-B55 (T42A)s on the register
Registration
N225DH · no longer on the register · serial TC-1271
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

During the initial climb, the landing gear warning horn sounded. The pilot diagnosed the problem and determined that the landing gear had retracted successfully and that the indication system was in error. He continued the flight with the horn intermittently sounding. During the descent phase, the pilot was given an unexpected direct route to the airport, and, as a result, he rushed through the descent checklist items. The pilot decided to perform a low pass over the arrival runway to confirm that the landing gear had extended. The pilot said that during the low pass he started to have difficulty controlling the airplane. An onboard engine monitoring system recorded a total loss of engine power to the right engine at that time. The pilot did not recognize that his difficulty in maintaining altitude and airplane control was a result of a loss of engine power to one engine; he subsequently lost control of the airplane, which collided with a storage facility in a nose-down inverted attitude. Witness reports, photographic evidence, and a postaccident examination revealed that the pilot did not retract the landing gear and flaps after the loss of power, as instructed in the airplane's operating instructions for a go-around with one engine inoperative. The airplane's operating instructions recommend that the main fuel tanks be selected during descent and while landing. The pilot stated that he customarily uses the auxiliary fuel tanks during cruise flight and the main tanks while climbing and descending; however, both fuel selector valves were found in the auxiliary tank position at the accident site. The airplane's fuel tanks were serviced to capacity about 2.5 flight hours before the accident. Calculations of fuel consumption for the flights since the last fueling would have resulted in the use of a quantity of fuel that would have either been equal to or slightly exceeded the capacity of the auxiliary fuel tanks. Damage to the fuel system precluded an accurate assessment of the quantity and distribution of the remaining fuel onboard at the time of the accident. The engine monitoring system recorded a small rise in exhaust gas temperatures just before the loss of power; this rise is consistent with a lean fuel/air mixture, which would be present in a fuel starvation or exhaustion event. The postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The pilot's increased workload, due to the unexpected routing and possible problem with the landing gear, during the abbreviated final approach clearance and subsequent low pass could have resulted in a task overload, which resulted in his mismanagement of the fuel system during the landing phase.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Fuel starvation during approach (VFR go-around) defining event
  2. Loss of engine power (total) during approach (VFR go-around)
  3. Loss of control in flight during approach (VFR go-around)
  4. Collision with terrain or object (not controlled flight into terrain) during uncontrolled descent

The NTSB's findings

  • Aircraft › Aircraft systems › Landing gear system › Gear position and warning › Malfunction
  • cause Personnel issues › Task performance › Use of equip/info › Use of equip/system › Pilot
  • cause Personnel issues › Action/decision › Info processing/decision › Identification/recognition › Pilot
  • cause Personnel issues › Action/decision › Action › Incorrect action performance › Pilot
  • factor Aircraft › Fluids/misc hardware › Fluids › Fuel › Fluid management
  • cause Personnel issues › Task performance › Workload management › Task overload › Pilot

Pilot

  • Certificate: private
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 660 hours in all; 101 in this make and model; 11 in the last 90 days; 3 in the last 30 days; 541 as pilot in command
  • Last flight review: August 8, 2010
  • Medical certificate: Class 3 (without waivers/limitations)
  • Seat: left
  • Injury: serious injuries

The aircraft

  • Airframe total time: 3,981 hours
  • Last inspection: annual inspection, June 23, 2010; 51 hours since
  • Maximum gross weight: 5,100 lb
  • Seats: 6
  • Landing gear: retractable
  • Engine 1: Cont Motor IO-470 (piston); 0 hours total
  • Engine 2: Cont Motor I0-470 SERIES (piston); 0 hours total

The flight

  • Departed from: SBP San Luis Obispo CA at 6:33 pm
  • Destination: SBD San Bernardino CA
  • Flight plan: IFR
  • Runway 24, 10,001 ft by 200 ft
  • A second pilot was aboard

Weather at the time

  • Light: daylight
  • Wind: from 240° at 4 knots
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 73°F (23°C), dew point 36°F (2°C)
  • Altimeter: 30.12 inHg
  • Observation at 7:58 pm from SBD, 1 miles away

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.