Pilot Debrief

BEECH A23 near Oxford, NC — 2013-06-13

Final reportERA13LA285
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Date
2013-06-13
Location
Oxford, NC, USA
Airport
HNZ
Aircraft
BEECH A23
Registration
N3542R
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Approach

Probable cause

The failure to comply with an airworthiness directive by maintenance personnel and incorrect reinstallation of the fuel selector handle by unknown personnel, which resulted in fuel starvation.

NTSB narrative

During the preflight inspection, the pilot/owner observed about 20 gallons of fuel in the left main fuel tank and significantly less fuel in the right main fuel tank. The pilot departed on a brief local flight with the fuel selector handle positioned to the left main fuel tank. About 10 minutes into the flight, the engine lost all power, and the flight instructor-rated passenger performed a forced landing to a field. During the landing, the airplane impacted a berm and sustained substantial damage to the left wing and fuselage. Examination of the wreckage revealed that the airplane's fuel selector handle was installed 180 degrees from its correct orientation. As such, when the handle portion of the selector was pointing at the desired tank, the pointer (arrow) was pointing in the opposite direction. Thus, when the pilot selected the left main fuel tank, the fuel selector valve was actually positioned to the right main fuel tank, which had little fuel at takeoff and was found empty after the accident. Additionally, the fuel selector handle was missing its roll pin, which allowed it to be installed incorrectly. Due to the fuel system design of return fuel going to the left main fuel tank only, the pilot primarily flew with the fuel selector positioned to the left main fuel tank. The fuel selector handle was often removed and reinstalled during maintenance inspections to allow access to the floor boards in the cockpit. An airworthiness directive (AD) for the fuel valve required repetitive inspection of the roll pin fuel valve during annual inspections per a manufacturer service instruction, or replacement of the roll pin valve with a D-handle type valve. Review of maintenance records revealed that about 38 years prior to the accident, a logbook entry indicated that the AD was complied with by installing a D-handle fuel valve; however, a roll pin type valve was installed at the time of the accident. Maintenance personnel performing subsequent inspections would assume, per the logbook entry, that the D-handle valve had been installed and any maintenance reference to the roll pin valve would not be applicable. The mechanic that performed the most recent annual inspection stated that he was not aware of a roll pin. The mechanic added that during the annual inspection, he removed and replaced the fuel selector handle to the same position he had found it. The pilot had owned the airplane for about 45 years and also performed some maintenance on it himself. The investigation could not determine when during the airplane's history that the fuel selector handle was installed incorrectly or by whom.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Properly inspecting and maintaining the fuel selector valve during annual inspections.

NTSB coding

Evidence available

  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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