ATL96LA127

NTSB accident investigation · Beech 33 · West Palm Beach, FL · September 16, 1996

Accident · Serious injuriesLimited investigationFinal report
Date
September 16, 1996, 07:27 local (11:27 UTC)
Place
West Palm Beach, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N108VWBeech 33
Weather
Visual (VMC) · Day
Status
Completed · report August 25, 1997
Report
Approved by Office Director
FAA report
19960916028489A
Case key
3759

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The maintenance personnel failure to properly inspect the fuel system during the last annual inspection.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfApproach
Fuel system,selector/valve - incorrectCause
Maintenance,annual inspection - inadequatePilot in commandCause
Supervision - inadequateOther maintenance personnelCause
Fluid,fuel - starvationCause
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency descent/landing

Analysis

The pilot was changing the fuel selector position from the left tank to the right tank when the engine lost power. He attempted an emergency landing; the airplane collided with the ground one mile west of the airport. Examination of the fuel selector valve assembly disclosed that the upper roll pin was not installed in the rotor assembly. A search of the wreckage at the accident site failed to recover the upper roll pin. An examination of the machined roll pin installation hole through the mast of the fuel selector, also failed to reveal evidence of a previous installation. Additionally, safety wire material was recovered from under the selector detent plate. A flow check of the fuel selector assembly disclosed that fuel flowed through the assembly without restriction. According to the annual inspection checklist, the fuel selector valve should be inspected for leakage. security, freedom, proper detent, and condition. The airframe maintenance logs showed that a current annual inspection had been accomplished. The pilot reportedly had performed the annual inspection under the supervision of an Authorized Inspector (AI).

Factual narrative

On September 16, 1996, at 0727 eastern daylight time, a Beech BE-33, N108VW, collided with the ground during an emergency landing following a complete loss of engine power near West Palm Beach, Florida. The personal flight operated under the provisions of Title 14 CFR Part 91 with an instrument flight plan activated. Visual weather conditions prevailed at the time of the accident. The airplane was substantially damaged, and the pilot received serious injuries. The flight departed Fort Pierce, Florida, at 0700.

According to the pilot's wife, he was changing the fuel selector from the left tank to the right tank when the engine lost power. The selector handle had reached the off position when the engine quit. The engine lost power, and the pilot attempted an emergency landing to the West Palm Beach North County Airport. The airplane collided with the ground one mile west of the airport.

Examination of the fuel selector valve assembly disclosed that upper roll pin was not installed in the rotor assembly. A search of the wreckage at the accident site failed to recover the upper roll pin. An examination of the machined roll pin installation hole through the mast of the fuel selector, also failed to reveal a previous roll pin installation. Additionally, lockwire material was recovered from under the yoke of the selector detent plate. The lockwire that should have been secured to the yoke was missing. No record of recent maintenance was recorded in aircraft maintenance logs. A flow check of the fuel selector assembly disclosed that fuel flowed through the assembly without restriction. According to the annual inspection checklist, the fuel selector valve should be inspected for leakage. security, freedom, proper detent, and condition. A current annual inspection had been accomplished on the airplane. Reportedly the pilot performed the annual inspection under the supervision of an Authorized Inspector (AI).

Aircraft

Registration
N108VW
Reported as
Beech 33
Category
Airplane
Serial number
CD-152
Airframe hours
4,086
Engine
Continental IO-470-J, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Arthur & Marianne Pearl
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 17, 1996
Departed
F88 · Fort Pierce, FL
Destination
FXE · Fort Lauderdale, FL
Flight plan
IFR
Airport
F45 · North County Airport, runway 13, 4,300 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
65
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
3,349 total · 1,300 in this make and model · 2,486 as pilot in command · 29 in the last 90 days · 17 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 70 °F
Altimeter
29.00 inHg
Observed at
PBI, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.