NTSB CAROL · Event
Event WPR19TA162
Aircraft involved
Probable cause & findings
The pilot’s mismanagement of fuel onboard, which resulted in a total loss of engine power due to fuel starvation.
Factual narrative
On June 8, 2019, about 1400 Pacific daylight time, a Beech 35 airplane, N602BH, was substantially damaged when it was involved in an accident near Rogue Valley International Airport (MFR), Medford, Oregon. The private pilot and his passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a statement from the pilot and passenger taken by a local law enforcement official, after departing MFR, the pilot began having engine trouble and returned to MFR. During the return portion of the flight, the engine quit several times. The airplane descended and struck a tree in a residential neighborhood about 1 mile from runway 32. According to a Federal Aviation Administration (FAA) inspector, the passenger told him the pilot started having engine trouble and resorted to “pumping up and down on a device that kept the engine running.” He said when the pilot stopped pumping, the engine would quit and when he pumped, it would run. Examination of the airplane by an FAA inspector revealed the main tanks "had plenty of gas", the aux tank was "nearly empty", and the tank selector switch was found in the auxiliary fuel tank position. Despite multiple attempts, the National Transportation Safety Board (NTSB) investigator-in-charge was unable to talk to the pilot regarding the accident and did not receive an NTSB Form 6120.1. A records search at Million Air, Medford recovered a fuel receipt for N602BH, dated for the same day as the accident, for 18.5 gallons of 100 low lead aviation gasoline. During the daytime visual flight rules flight, the private pilot experienced engine trouble. He was able to keep the engine running utilizing the auxiliary fuel pump and diverted to the departure airport. The pilot was unable to make it to the airport and descended into a residential neighborhood where the airplane was substantially damaged when it struck a tree. Postaccident examination of the airplane revealed that the main fuel tanks had a sufficient quantity of fuel and that the auxiliary fuel tank was nearly empty. The fuel selector valve handle was found in the auxiliary fuel tank position. It is likely the pilot did not position the fuel selector switch to one of the main fuel tanks prior to consuming all the useable fuel in the auxiliary tank. This omission likely resulted in a total loss of engine power due to fuel starvation. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot
- — Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid management
Verbatim from NTSB's published report. Source file
NTSB_2019_WPR19TA162.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (fuel starvation). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2025 · Journal article (JAAER)
Editor's Note: Celebrating 35 Years of Scholarly Excellence
A letter from the editor, Dr. Dahai Liu, on the JAAER's 35th anniversary.
- NASA NTRS 2024 · Presentation
Part 135 and Business Operator Low Altitude Events: An Analysis of ASRS Reports
This presentation provides an aviation SME's human factors analysis of selected Low Altitude and Controlled Flight Towards Terrain (CFTT) events involving Part 135 and business jet operators as report…
- NASA NTRS 2022 · Conference Paper
The In-time Aviation Safety Management System Concept for Part 135 Operators
Transformations of the National Airspace System, such as envisioned with Advanced Air Mobility, will enable improvements for managing and assuring safety for Part 135 transportation of passengers and …
- Embry-Riddle Scholarly Commons 2022 · Journal article (JAAER)
SMS for Part 135 Commuter and On-Demand Operations - The Practitioner’s Perspective
On May 15th, 2017, N452DA, a Learjet 35A operated by Trans-Pacific Air Charter, LLC, departed from Philadelphia to Teterboro, New Jersey (TEB) on a positioning flight under 14 Code of Federal Regulati…
- NTSB Aircraft Accident Reports 2021 · Accident report
Crash of Atlas Air Flight 3591, Boeing 767-300 (N1217A)
Atlas Air 3591 crashed into Trinity Bay, Texas, February 23, 2019. Investigation of the in-flight loss-of-control crash of Atlas Air 3591 into Trinity Bay, Texas.
- Embry-Riddle Scholarly Commons 2020 · Journal article (IJAAA)
Analysis of Part 135 Aircraft Accidents to Facilitate Flight Data Monitoring
The scheduled and on-demand air services with Title 14 Code of Federal Regulations (CFR) Part 135 certificate are operating with relatively less stringent safety program criteria compared to Part 121 …
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