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ERA13LA285 · Beech A23

13 Jun 2013 · Oxford, NC, United States

Beech A23 · Accident: fuel starvation on approach

From Henderson Oxford Airport (HNZ) to Henderson Oxford Airport (HNZ)

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Event

NTSB case
ERA13LA285
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Beech A23

Aircraft type
Beechcraft 23
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N3542R
Onboard fatalities
Unknown
Route
From Henderson Oxford Airport (HNZ), Oxford, NCTo Henderson Oxford Airport (HNZ), Oxford, NC
Aircraft age
About 48 years (built 1965)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Fuel starvation
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Aircraft › Aircraft systems
  • Personnel issues › Task performance

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

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.

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.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record ERA13LA285
Event ID
20130613X40838
Case number
ERA13LA285
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 6c163bfa106bf8a83d6da81aa367de35cdb5669b56307521782f1fcd0ea5c85f; retrieved 2026-09-15T21:51:51.841Z.