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Aviation safety reports, made easier to study

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NTSB Report

November 12, 1994 · Beech A23 · N3584R

Campbellsville, KY

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
November 12, 1994
Injury Outcomes
No injuries (2 uninjured)
Location
Campbellsville, KY
Aircraft
Beech A23
Tail Number
N3584R
Operator
Dianne M Wolf Mc Dowell
Injuries
None
Aircraft Damage
Substantial
NTSB Number
BFO95LA012

WHILE IN CRUISE FLIGHT, 2 HOURS AFTER DEPARTURE, THE AIRPLANE ENGINE LOST TOTAL POWER AND AN OFF AIRPORT LANDING WAS MADE. POSTACCIDENT EXAMINATION OF THE FUEL SYSTEM REVEALED THE LEFT FUEL TANK CONTAINED USEABLE FUEL AND THE RIGHT FUEL TANK WAS EMPTY. NO FUEL LEAKS WERE NOTED. THE PILOT SAID THE FUEL SELECTOR WAS SELECTED TO THE LEFT TANK FOR THE ENTIRE FLIGHT. EXAMINATION OF THE FUEL SELECTOR ASSEMBLY REVEALED THE PIN THAT ALIGNS THE FUEL SELECTOR HANDLE WITH THE FUEL SELECTOR VALVE WAS MISSING. THE FUEL SELECTOR HANDLE WAS OFFSET 90-DEGREES FROM THE VALVE. WHEN THE FUEL SELECTOR HANDLE WAS POSITIONED ON THE LEFT TANK, THE VALVE WAS POSITIONED ON THE RIGHT TANK. THE AIRPLANE HAD RECEIVED AN ANNUAL INSPECTION THREE DAYS PRIOR TO THE ACCIDENT. THE MECHANIC SAID THAT HE ALIGNED THE VALVE AND HANDLE WITH THE PIN IN PLACE.

NTSB Probable Cause

the mechanic's improper maintenance adjustment, which involved the misalignment of the fuel selector handle with the fuel selector valve. Related factors are the pilot's inadequate fuel management, and the rough/uneven terrain.

Full Narrative

On November 12, 1994, at 0845 eastern standard time, a Beech A23, N3584R, lost total engine power during cruise flight. A forced landing was made on a road near Campbellsville, Kentucky. The pilot and passenger were not injured. The airplane was substantially damaged. Visual meteorological conditions prevailed. The instrument flight rules flight departed Indianapolis, Indiana, and was destined for Chattanooga, Tennessee. The flight was operated under 14 CFR Part 91. According to a Federal Aviation Administration Inspector, the pilot reported that while in cruise flight the airplane engine lost total power and despite all emergency procedures accomplished, it would not restart. The pilot reported that he tried to land the airplane at a nearby airport but it did not have enough altitude or airspeed to make the airport. The pilot said he landed the airplane on a road and had to turn it off the road to avoid a car. He stated that when the airplane departed the road, the left main gear collapsed damaging the fuselage, stabilizer, and left wing. According to the passenger, who was also the owner of the airplane, she and the pilot both did a preflight prior to departure. She stated that both fuel tanks were full and there was no evidence of fuel leakage prior to departure. The passenger stated that the engine quit about two hours after departure. She stated the fuel selector was selected to the left tank the entire flight. She said she did not notice what the fuel gauges were reading during the flight. Postaccident examination of the fuel system revealed no anomalies with the fuel pump and fuel gauges. The fuel selector was positioned on the left fuel tank. No fuel leaks were found throughout the system. The left fuel tank had an undetermined amount of fuel in it and the right fuel tank was empty. The fuel selector assembly was tested and the fuel selector handle was found to be offset 90 degrees from the attached fuel selector valve. The fuel selector handle and valve should be aligned. When the fuel selector handle was positioned on the left tank, the fuel selector valve was selected to the right fuel tank. When the fuel selector handle was positioned on the right tank, the fuel selector valve was positioned in the "OFF" position. The pin that aligns the fuel selector handle and valve was missing. According to the Beech A23 Pilot Operating Handbook (POH), "A fuel return line from the engine-driven fuel pump returns approximately 3 to 6 gallons of fuel per hour to the left tank when the engine is operating at 75 % power or less." Any excessive fuel in a fuel tank will be drained overboard through the fuel vent line. The airplane had a fuel capacity of about 60 gallons (29.9 gallon capacity each fuel tank.) According to the POH, a maximum fuel flow for the airplane is 9.3 gallons per hour. According to the airplane's log books, the airframe and engine had received an annual inspection on November 9, 1994, three days prior to the accident. Since the annual inspection, the airplane had been flown about 2 1/2 hours. Examination of the annual inspection entry in the airplane's log book showed the mechanic had documented the annual inspection and near the end of the entry stated "...freed up the fuel selector valve...." During an interview with an FAA Safety Inspector, the mechanic stated that he aligned the fuel selector handle and valve using the alignment pin. He stated that after he re-installed the fuel selector, he tested its operation by verifying the operation of each position and by complying with Airworthiness Directive 75- 01-04 (See attached AD).

Flight

Event TypeAccident
Event Time08:45 EST
Nearest Airport0nm
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBeech A23
Tail NumberN3584R
Aircraft CategoryAir
DamageSubstantial
OperatorDianne M Wolf Mc Dowell
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · IO-346-A23 · Reciprocating · 165
Seats4

People & Injuries

Injury SummaryNo injuries (2 uninjured)
Fatal0
Serious0
Minor0
Uninjured2
Total2
Crew 1Age 69 · Third Class

Conditions

ConditionsVMC
LightDaylight
WindCalm
Visibility10 sm
CeilingOvercast 3200 ft
Temperature / Dew Point52 / 46
Altimeter30.00 inHg
Observation Time14:06
Weather SourceWFAC

Appendix: Source Data