BEECH C23 — Winter Haven, FL, 2010

BEECH C23 — Winter Haven, FL

2 fatal Low altitude

Date	February 25, 2010
Location	Winter Haven, FL
Aircraft	BEECH C23
Purpose of flight	Personal
Conditions	Day · Visual Meteorological Cond
Phase / occurrence	Maneuvering Aerodynamic stall/spin
Pilot age	45
Pilot total time	469 hrs · Building experience
Time in type	6 hrs
Fatalities	2

Probable cause

The pilot’s improper placement of the fuel selector valve during takeoff, and his failure to maintain adequate airspeed following a total loss of engine power resulting in an inadvertent stall. Contributing to the accident was the failure of maintenance personnel to detect the lack of proper markings on the fuel selector stop and fuel selector valve shroud at the last 100-Hour inspection.

NTSB findings

Aircraft-Aircraft systems-Fuel system-Fuel selector/shutoff valve-Incorrect use/operation - C
Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
Personnel issues-Task performance-Inspection-Scheduled/routine inspection-Maintenance personnel - F
Aircraft-Aircraft handling/service-Maintenance/inspections-(general)-Not specified

What happened

During the initial climb after takeoff, the engine lost power, and the airplane stalled and impacted the ground. A postaccident examination of the airframe and engine revealed no mechanical malfunctions that would have precluded normal operation. The fuel selector was observed in the off range after the accident and immediate postaccident testing of the selector valve revealed no mechanical anomalies. While the pilot’s cockpit actions pertaining to the fuel selector valve following the loss of engine power could not be determined, the lack of a preimpact mechanical failure of the engine or its systems, and the lack of an issue related to fuel quality are consistent with the fuel selector valve being in the off range for takeoff. Inspection and operational testing of the fuel selector valve was reportedly performed as required during the last annual and 100-Hour inspections; however, no guidance was given to maintenance personnel on how to perform the operational shutdown test. Different interpretations of what constituted proper engine shutdown was noted by the mechanics that performed the last annual and 100-Hour inspections. The mechanic who performed the last 100-Hour inspection approximately 6 months prior to the accident failed to detect that the fuel selector valve guard and stop did not contain required markings which clearly depict the off range for the pilot.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.