Pilot Debrief

BEECH C23 near Winter Haven, FL — 2010-02-25

Final reportERA10FA150
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Date
2010-02-25
Location
Winter Haven, FL, USA
Airport
GIF
Aircraft
BEECH C23
Registration
N180ED
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Initial climb

Probable cause

The pilot’s improper placement of the fuel selector valve during takeoff, and his failure to maintain adequate airspeed following a total loss of engine power resulting in an inadvertent stall. Contributing to the accident was the failure of maintenance personnel to detect the lack of proper markings on the fuel selector stop and fuel selector valve shroud at the last 100-Hour inspection.

Contributing factors

Contributing to the accident was the failure of maintenance personnel to detect the lack of proper markings on the fuel selector stop and fuel selector valve shroud at the last 100-Hour inspection.

NTSB narrative

During the initial climb after takeoff, the engine lost power, and the airplane stalled and impacted the ground. A postaccident examination of the airframe and engine revealed no mechanical malfunctions that would have precluded normal operation. The fuel selector was observed in the off range after the accident and immediate postaccident testing of the selector valve revealed no mechanical anomalies. While the pilot’s cockpit actions pertaining to the fuel selector valve following the loss of engine power could not be determined, the lack of a preimpact mechanical failure of the engine or its systems, and the lack of an issue related to fuel quality are consistent with the fuel selector valve being in the off range for takeoff. Inspection and operational testing of the fuel selector valve was reportedly performed as required during the last annual and 100-Hour inspections; however, no guidance was given to maintenance personnel on how to perform the operational shutdown test. Different interpretations of what constituted proper engine shutdown was noted by the mechanics that performed the last annual and 100-Hour inspections. The mechanic who performed the last 100-Hour inspection approximately 6 months prior to the accident failed to detect that the fuel selector valve guard and stop did not contain required markings which clearly depict the off range for the pilot.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked fuel selector position before takeoff.

NTSB coding

Evidence available

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

Docket documents33

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