ATL96LA127
1996-09-16 · WEST PALM BEACH, Florida, United States · Serious · 1 aircraft · Status: Completed
Airport F45
Aircraft involved
Probable cause & findings
The maintenance personnel failure to properly inspect the fuel system during the last annual inspection.
Factual narrative
On September 16, 1996, at 0727 eastern daylight time, a Beech BE-33, N108VW, collided with the ground during an emergency landing following a complete loss of engine power near West Palm Beach, Florida. The personal flight operated under the provisions of Title 14 CFR Part 91 with an instrument flight plan activated. Visual weather conditions prevailed at the time of the accident. The airplane was substantially damaged, and the pilot received serious injuries. The flight departed Fort Pierce, Florida, at 0700. According to the pilot's wife, he was changing the fuel selector from the left tank to the right tank when the engine lost power. The selector handle had reached the off position when the engine quit. The engine lost power, and the pilot attempted an emergency landing to the West Palm Beach North County Airport. The airplane collided with the ground one mile west of the airport. Examination of the fuel selector valve assembly disclosed that upper roll pin was not installed in the rotor assembly. A search of the wreckage at the accident site failed to recover the upper roll pin. An examination of the machined roll pin installation hole through the mast of the fuel selector, also failed to reveal a previous roll pin installation. Additionally, lockwire material was recovered from under the yoke of the selector detent plate. The lockwire that should have been secured to the yoke was missing. No record of recent maintenance was recorded in aircraft maintenance logs. A flow check of the fuel selector assembly disclosed that fuel flowed through the assembly without restriction. According to the annual inspection checklist, the fuel selector valve should be inspected for leakage. security, freedom, proper detent, and condition. A current annual inspection had been accomplished on the airplane. Reportedly the pilot performed the annual inspection under the supervision of an Authorized Inspector (AI). The pilot was changing the fuel selector position from the left tank to the right tank when the engine lost power. He attempted an emergency landing; the airplane collided with the ground one mile west of the airport. Examination of the fuel selector valve assembly disclosed that the upper roll pin was not installed in the rotor assembly. A search of the wreckage at the accident site failed to recover the upper roll pin. An examination of the machined roll pin installation hole through the mast of the fuel selector, also failed to reveal evidence of a previous installation. Additionally, safety wire material was recovered from under the selector detent plate. A flow check of the fuel selector assembly disclosed that fuel flowed through the assembly without restriction. According to the annual inspection checklist, the fuel selector valve should be inspected for leakage. security, freedom, proper detent, and condition. The airframe maintenance logs showed that a current annual inspection had been accomplished. The pilot reportedly had performed the annual inspection under the supervision of an Authorized Inspector (AI). Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1996_ATL96LA127.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
Related research
Matched on aircraft type or causal vocabulary (stall, maintenance). All research papers
- arXiv 2020 · arXiv preprint A Lean and Highly-automated Model-Based Software Development Process Based on DO-178C/DO-331
The emergence of a global market for urban air mobility and unmanned aerial systems has attracted many startups across the world.
- NASA NTRS 1995 · Conference Paper Human Factor Implications of the Eurocopter AS332L-1 Super Puma cockpit
The purpose of this paper is to identify and describe some of the human factor problems which can occur in the cockpit of a modern civilian helicopter.
- AOPA Air Safety Institute 2024 · Annual report (Nall Report) 33rd Joseph T. Nall Report — General Aviation Accidents in 2022
The annual Joseph T. Nall Report from the AOPA Air Safety Institute summarizes general aviation accidents and causal factors for calendar year 2022.
- Embry-Riddle Scholarly Commons 2023 · Conference paper The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2020 · Conference paper Certificated AMTs: What Will Encourage More Women to Become Aviation Maintenance Technicians?
This paper examines practices that are used in STEM fields to attract women in order to understand how those tactics may to entice women to join the ranks of certified AMTs.
- Embry-Riddle Scholarly Commons 2017 · Conference paper The Application of Shared Leadership in an Aviation Maintenance MTS Environment
The use of a multiteam system approach has been proven useful for many organizational environments, notably those that operate in dynamic and demanding surroundings.