# NTSB ATL96LA127: Beech 33, N108VW, West Palm Beach, FL, September 16, 1996 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 16, 1996, 07:27 local (11:27 UTC) - Place: West Palm Beach, FL - Coordinates: 26.789142, -80.210021 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.7891&lon=-80.2100&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report August 25, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 3759 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL96LA127 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3759/pdf - Page: https://openairdocs.org/ntsb/ATL96LA127 ## Probable cause The maintenance personnel failure to properly inspect the fuel system during the last annual inspection. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, approach - fuel system,selector/valve - incorrect (cause) - maintenance,annual inspection - inadequate, pilot in command (cause) - supervision - inadequate, other maintenance personnel (cause) - fluid,fuel - starvation (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency 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](https://openairdocs.org/deregistered/N108VW-1997-12-06), registration cancelled 1997-12-06, S/N CD152 (OpenAirDocs) - Reported make and model: Beech 33 - Registry model: [Beech 35-33](https://openairdocs.org/model/beech-35-33) (registry code 1151402) (OpenAirDocs) - Category: Airplane - Serial number: CD-152 - Airframe hours: 4086 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; 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 (OpenAirDocs). - [Accident 19960916028489A](https://openairdocs.org/incident/19960916028489A), Sep 16, 1996: Beech 3533, West Palm Beach, FL, Substantial damage. Lost power during switching from left tank to right tank. Fuel selector missing roll pin. Pilot performed annual. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.