Accident Overview
On June 13, 2013, at approximately 1010 eastern daylight time, a Beech A23 (registration N3542R) operated by a private individual was substantially damaged during a forced landing to a wheat field. The forced landing followed a total loss of engine power during approach to Henderson-Oxford Airport (HNZ), Oxford, North Carolina. The commercial pilot and flight instructor on board received minor injuries. The flight was conducted under 14 CFR Part 91 in visual meteorological conditions, and no flight plan was filed. The local flight had originated from HNZ about 1000.
Flight History
The flight instructor reported that the commercial pilot had a medical condition requiring him to fly with a certified flight instructor per his insurance carrier. The commercial pilot performed the preflight inspection while the flight instructor retrieved headsets; thus, the flight instructor did not witness the preflight. Upon return, the commercial pilot stated there were 20 gallons of fuel in the left main tank and a lesser quantity in the right main tank, confirmed by fuel gauges. After an uneventful departure from runway 24, the commercial pilot completed one touch-and-go landing, and the flight instructor also completed one touch-and-go. The flight instructor then flew at about 2,000 feet above ground level toward a navigational beacon for a practice instrument approach. About half a mile from the beacon, the flight instructor noticed engine power decrease from 2,300 rpm to 2,000 rpm. He performed a 180-degree turn back toward HNZ; during the turn, engine power twice increased to 2,300 rpm then decreased to 2,000 rpm. At turn completion, the engine lost all power.
Fuel Selector Actions and Landing
While gliding toward the airport, the commercial pilot moved the fuel selector from left to right main tank. The engine momentarily regained power to 2,000 rpm but then lost all power again. The flight instructor activated the boost pump, and the engine similarly regained power briefly before total loss. Unable to glide to the airport, the flight instructor executed a forced landing to a field.
Post-Accident Examination
A Federal Aviation Administration (FAA) inspector noted that during landing, the airplane struck a berm, causing substantial damage to the left wing and fuselage. The right main fuel tank was intact and empty; the left main tank was compromised, with about 2 gallons remaining, though an undetermined amount leaked post-impact. The wreckage was moved to a hangar for examination under FAA supervision.
The examination revealed that at some point in the airplane's history, the fuel selector handle had been reinstalled approximately 180 degrees from its correct orientation. Consequently, when the handle pointed to a desired tank, the pointer arrow pointed 180 degrees away. The fuel selector handle was typically removed during maintenance inspections for floor board access, and its roll pin was missing, allowing incorrect installation. With the roll pin installed, the handle could only be installed in one direction. When the left main tank was selected, the valve actually selected the right tank; when the right was selected, the valve was in the off position.
Maintenance and Airworthiness Directive
According to the airplane owner's manual, each wing held a 29.9-gallon fuel tank, but due to a fuel return line only to the left tank, 15 gallons had to be used from the left tank first. The pilot primarily operated with the selector on the left tank. Airworthiness Directive (AD) 75-01-04, issued January 7, 1975, aimed to prevent improper fuel selector movement and ensure shutoff. Compliance could be achieved by replacing the roll pin valve with a D-handle valve or inspecting the roll pin valve annually per Beechcraft Service Instruction 0364-289 Rev III. An airframe logbook entry dated April 2, 1975, stated AD compliance via installation of a D-handle valve (part number 169-380086-1); however, an older roll pin valve was installed at the time of the accident. Therefore, subsequent inspections would assume a D-handle valve was present, making references to the roll pin valve in manuals seem obsolete.
The airplane's most recent annual inspection was completed on May 6, 2013, with about 1 hour of flight time since. The mechanic who performed the inspection stated he was unaware of a roll pin and that the maintenance manual did not mention one. He removed and replaced the fuel selector handle in the same position he found it. The FAA inspector noted that the pilot owned the airplane (manufactured in 1965) for 45 years and performed some maintenance himself. It could not be determined when the fuel selector handle was incorrectly installed or by whom.