Henderson-Oxford Airport
Aircraft Accident/Incident Report

Oxford, North Carolina 27565
Thursday, June 13, 2013 10:10 EDT

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 6/13/2013
Event Day of the Week Thursday
Time of Event 1010
Event Time Zone Eastern Daylight Time
Event City Oxford
Event State NORTH CAROLINA
Event Country --
Zipcode of the event site 27565
Event Date Year 2013
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 362142N
Event Location Longitude 0783145W
Event Location Airport Henderson-Oxford Airport
Event Location Nearest Airport ID HNZ
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 1
Degrees magnetic from airport --
Airport Elevation 526
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1015 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 240
Weather Observation Facility ID HNZ
Elevation of weather observation facility 526
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 29
Dew Point at event time (in degress fahrenheit) 22
Wind Direction (degrees magnetic) 230
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.77
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 2
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 32652
NTSB Notification Source FAA Southern ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Mar 11 2014 3:37PM
User who most recently changed record kenj
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N3542R
NTSB Number ERA13LA285
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BEECH
Aircraft Model A23
Aircraft Series Identifier --
Aircraft Serial Number M-710
Certified Max Gross Weight 2350
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats --
Passenger Seats 2
Total number of seats on the aircraft 4
Number of Engines 18
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection May 6 2013 12:00AM
Airframe hours since last inspection 1
Airframe Hours 2201
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type C91
Aircraft Owner Name WEHE ALBERT H
Aircraft Owner Street Address --
Aircraft Owner City RALEIGH
Aircraft Owner State NC
Aircraft Owner Country USA
Aircraft Owner Zipcode 27613
Operator is an individual? No
Operator Name WEHE ALBERT H
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City RALEIGH
Operator State NC
Operator Country USA
Operator Zip code 27613
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code HNZ
Departure City Oxford
Departure State NC
Departure Country USA
Departure Time 1000
Departure Time Zone EDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code HNZ
Destination City Oxford
Destination State NC
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Mar 11 2014 3:37PM
User who most recently changed record kenj
Since inspection or accident Last Inspection
Event Location Runway Number and Location 24
Runway Length 5002
Runway Width 97
Sight Seeing flight No
Air Medical Flight No
Medical Flight --