# NTSB ERA13LA285: Beech A23, N3542R, Oxford, NC, June 13, 2013 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: June 13, 2013, 10:10 local (14:10 UTC) - Place: Oxford, NC - Coordinates: 36.361667, -78.529167 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.3617&lon=-78.5292&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report June 2, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - ADs cited in the narratives: [AD 75-01-04](https://openairdocs.org/ad/75-01-04) (OpenAirDocs) - NTSB case key (mKey): 87187 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA285 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87187/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87187 - Page: https://openairdocs.org/ntsb/ERA13LA285 ## 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. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=1151204), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=1151204), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Other (probable cause); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1151204), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Beech A23, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=1151204), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech A23, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151204), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A23, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151204), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A23, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151204), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A23, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151204), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis 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. ## Factual narrative On June 13, 2013, about 1010 eastern daylight time, a Beech A23, N3542R, operated by a private individual, was substantially damaged during a forced landing to a wheat field, following a total loss of engine power during approach to Henderson-Oxford Airport (HNZ), Oxford, North Carolina. The commercial pilot and flight instructor incurred minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that originated from HNZ about 1000. The flight instructor reported that the commercial pilot had a medical condition for which his insurance carrier required him to fly with a certified flight instructor. The commercial pilot performed the preflight inspection of the airplane while the flight instructor retrieved headsets from a fixed based operator. As such, the flight instructor did not witness the preflight inspection. When the flight instructor returned, the commercial pilot told him there were 20 gallons of fuel in the left main fuel tank and "a lesser" quantity in the right main fuel tank, which was confirmed by the fuel gauges. The airplane departed runway 24 uneventfully and the commercial pilot completed one touch-and-go landing. The flight instructor also completed one touch-and-go landing and then flew at an altitude about 2,000 feet above ground level toward a local navigational beacon for a practice instrument approach. About 1/2 mile from the beacon, the flight instructor noticed that the engine power decreased from 2,300 rpm to 2,000 rpm. The flight instructor performed a 180-degree turn back toward HNZ and noticed that during the turn, the engine power twice increased to 2,300 rpm, followed by a degrease to 2,000 rpm. At the completion of the turn, the engine lost all power. While gliding toward the airport, the commercial pilot moved the fuel selector from the left main fuel tank position to the right main fuel tank position. Subsequently, the engine momentarily regained power to 2,000 rpm, but then lost all power again. The flight instructor turned on the boost pump and similarly the engine regained power to 2,000 rpm, followed by a total loss of power. The flight instructor was not able to glide the airplane to the airport and performed a forced landing to a field. According to a Federal Aviation Administration (FAA) inspector, during the landing, the airplane impacted a berm and sustained substantial damage to the left wing and fuselage. The inspector observed that the right main fuel tank remained intact and did not contain any fuel. The left main fuel tank was compromised during the accident. About 2 gallons of fuel remained in the left main fuel tank; however, an undetermined amount of fuel leaked from the left wing after impact. The wreckage was subsequently recovered to a hangar and examined under the supervision of an FAA inspector. The examination revealed that at some point inthe airplane's history, the fuel selector handle had been reinstalled approximately 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 180 degrees away from the desired fuel tank. The FAA inspector stated that the fuel selector handle was usually removed during maintenance inspections to facilitate access to the floor boards in the cockpit. Additionally, the fuel selector handle was missing its respective roll pin, which would allow it to be installed incorrectly. With the roll pin installed, the fuel selector handle could only be installed in one direction. When the left main fuel tank was selected, the fuel selector valve was actually positioned to the right main fuel tank. When the right main fuel tank was selected, the fuel selector valve was in the off position. Review of the airplane owner's manual revealed that one 29.9-gallon capacity fuel tank was located in each wing. Due to the fuel return going to the left main fuel tank only, the owner's manual cautioned that 15 gallons must be used from the left fuel tank first. Therefore, the pilot primarily operated the airplane with the fuel selector positioned to the left main fuel tank. Airworthiness directive (AD) 75-01-04 was issued by the FAA on January 7, 1975, to reduce the possibility of improper or unintentional movement of the fuel selector valve, prevent binding and ensure complete shutoff of the selector valve in the "Off" position. According to the FAA inspector that examined the wreckage, the AD was applicable to the accident airplane, and could have been complied with by either replacing a roll pin fuel selector valve with a D-handle valve, or inspecting the roll pin valve at every subsequent annual inspection per Beechcraft Service Instruction (SI) 0364-289 Rev III. An entry in the airframe logbook, dated April 2, 1975, stated that AD 75-01-04 was complied with by the installation of valve part number 169-380086-1(D-handle); however, an older roll pin valve was installed in the airplane at the time of the accident. Therefore, mechanics performing subsequent inspections would assume, per the logbook entry, that a newer D-handle valve had been installed and any reference to a roll pin fuel valve in the shop manual (maintenance manual) or SI would not be applicable as it was dated information and superseded by the AD. Review of the airframe logbook revealed that the airplane's most recent annual inspection was completed on May 6, 2013. The airplane had accumulated about 1 hour of flight time since the most recent annual inspection. The FAA inspector interviewed the mechanic who completed the most recent annual inspection. That mechanic stated that he was not aware of a roll pin and there was no mention of a roll pin in the maintenance manual. The mechanic added that during the annual inspection, he removed and replaced the fuel selector handle to the same position he had foundit. The FAA inspector further stated that the pilot had owned the airplane, which was manufactured in 1965, for 45 years and also performed some maintenance on it himself. The inspector could not be sure when during the airplane's history that the fuel selector handle was installed incorrectly or by whom. ## Aircraft - Registration: [N3542R](https://openairdocs.org/deregistered/N3542R-2015-05-12), registration cancelled 2015-05-12, S/N M-710, built 1965 (OpenAirDocs) - Reported make and model: BEECH A23 - Registry model: [Beech A23](https://openairdocs.org/model/beech-a23) (registry code 1151204) (OpenAirDocs) - Registry engine: [Continental IO-346 series](https://openairdocs.org/engine/continental-io-346-series) (registry code 17033, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-710 - Year built: 1965 - Airframe hours: 2201 - Engines: CONT MOTOR IO-346 165 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Wehe Albert H - Registered owner: Wehe Albert H - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 6, 2013, 1 hours before - Departed: HNZ, Oxford, NC - Destination: HNZ, Oxford, NC - Airport: HNZ, Henderson-Oxford Airport, runway 24, 5,002 × 97 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 81; injuries: minor; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review March 1, 2011; seat: left; restraint: lap only; flight hours: 2,220 total, 1,900 in this make and model, 2,110 as pilot in command, 1 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours - Flight instructor; age 51; injuries: minor; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review September 9, 2011; seat: right; restraint: lap only; flight hours: 1,088 total, 0 in this make and model, 1,025 as pilot in command, 140 in the last 90 days, 50 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 72 °F - Altimeter: 29.77 inHg - Observed at: HNZ, 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 20130613010629A](https://openairdocs.org/incident/20130613010629A), Jun 13, 2013: Beech A23, Oxford, NC, Substantial damage. This office arrived at the accident site at approximately 1330 hours to investigate N3452R. The aircraft landed in a wheat field tearing off the nose gear and… ## Docket (14 files) The files NTSB released with the investigation on March 14, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87187. 3.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407232&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Flight Instructor Statement (item 2, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407234&FileExtension=.PDF&FileName=Flight%20Instructor%20Statement-Master.PDF - FAA Inspector Statement (item 3, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407235&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF - Interview Summaries (item 4, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407236&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Excerpts From Airframe Logbooks (item 5, .PDF, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407241&FileExtension=.PDF&FileName=Excerpts%20From%20Airframe%20Logbooks-Redacted.PDF - Airworthiness Directive 75-01-04 (item 6, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407237&FileExtension=.PDF&FileName=Airworthiness%20Directive%2075-01-04-Master.PDF - Beechcraft Service Instruction 0364-289, Rev. III (item 7, .PDF, 718 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407239&FileExtension=.PDF&FileName=Beechcraft%20Service%20Instruction%200364-289,%20Rev.%20III-Master.PDF - Excerpt From Beechcraft Shop Manual (Maintenance Manual) (item 8, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407240&FileExtension=.PDF&FileName=Excerpt%20From%20Beechcraft%20Shop%20Manual%20(Maintenance%20Manual)-Master.PDF - Excerpts From Airplane Owner's Manual (item 9, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407875&FileExtension=.PDF&FileName=Excerpts%20From%20Airplane%20Owner%27s%20Manual-Master.PDF - Excert From Service Bulletin (Depiction of Fuel Selector) (item 10, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407877&FileExtension=.PDF&FileName=Excert%20From%20Service%20Bulletin%20(Depiction%20of%20Fuel%20Selector)-Master.PDF - FAA SDR (item 11, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407247&FileExtension=.PDF&FileName=FAA%20SDR-Master.PDF - Photograph # 1: Wreckage (Photo Courtesy of FAA) (item 12, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407242&FileExtension=.PDF&FileName=Photograph%20%23%201%3A%20%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 2: Fuel Selector (Photo Courtesy of FAA) (item 13, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407243&FileExtension=.PDF&FileName=Photograph%20%23%202%3A%20%20Fuel%20Selector%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photograph # 3: Fuel Selector Valve (Photo Courtesy of A&P Kellogg) (item 14, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407244&FileExtension=.PDF&FileName=Photograph%20%23%203%3A%20%20Fuel%20Selector%20Valve%20(Photo%20Courtesy%20of%20A%26P%20Kellogg)-Master.PDF 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.