NTSB Factual Report

HISTORY OF FLIGHT

On February 6, 1994, at 1221 hours central standard time, a Beech BE-95 Travel-Air, N9903R, registered to CY Aviation Leasing of Pacific, Missouri, and operated under 14 CFR Part 91, entered the traffic pattern to land at Spirit of St. Louis Airport, Chesterfield, Missouri, the pilot reported "a problem," and the airplane impacted the ground 2 miles southeast of runway 26L. The airplane was destroyed. The instrument rated private pilot and instrument rated private pilot passenger sustained fatal injuries. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight originated from Spirit of St. Louis Airport at 1150 hours.

The aircraft had been flown 1.3 hours in the local area immediately prior to the mishap flight by the instrument rated private pilot passenger. The engine tachometer time was logged to be 4.6 hours. After the initial flight by the mishap passenger, the mishap pilot boarded and assumed the left seat. The mishap flight departed without refueling, and flew 0.8 hours with the tachometer indicating 5.4 hours at impact. Tachometer time since refueling was 2.1 hours. The aircraft was refueled on February 5, 1994, receiving 30.8 gallons, all of which was placed in the left auxiliary fuel tank. The other 3 tanks were observed to be full at that time by the servicing lineman.

PERSONNEL INFORMATION

The 66 year old pilot-in-command held a private pilot certificate number 498220296, with privileges for single and multiengine instrument flight. He had a total time of 531 hours of which 175 hours was in multiengine airplanes, all in the accident airplane. He held a third class medical certificate issued September 15, 1992, with the limitation of "must wear corrective lenses." His most recent biennial flight review was completed on April 27, 1993, in the accident airplane. The pilot's most recent flight experience, according to his personal logbook, was on June 17, 1993. The accident airplane trip log indicated the pilot had flown on December 27, 1993, for 0.7 hours.

The 56 year old passenger held a private pilot certificate number 500347805, with privileges for single and multiengine instrument flight. He had a total time of 678 hours at the time of the accident according to his personal logbook. He held a third class medical certificate issued April 21, 1992, with the limitation of "must wear corrective lenses." The passenger's most recent flight immediately preceded the accident flight.

AIRCRAFT INFORMATION

The airplane was a Beech BE-95 Travel Air, N9903R, serial number TD-389. The airplane had accumulated 2,148 hours at the time of the accident. The last annual inspection was completed on November 1, 1993.

At completion of the annual inspection, Beech Aircraft Mandatory Service Bulletin (MSB) #2449 was installed. The purpose of this MSB was to provide an Auxiliary Fuel Tank Annunciator Light which would illuminate if either fuel selector valve handle was positioned to the "Aux" position and the landing gear was extended.

COMMUNICATIONS

The pilot contacted Spirit of St. Louis Tower and entered the landing pattern for runway 26L. The pilot then stated he was having "a problem." No further communications were received.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted in an open field approximately 2 miles southeast of the approach end of runway 26L. Impact scars containing landing light glass and a broken engine alternator belt pulley were located in line with a ground scar containing paint chips of the same color as the right wing. At the end of the scar with paint chips was green broken glass. The airplane was located 11 feet southeast of these ground scars with the nose pointing 350 degrees magnetic.

The empennage was intact and exhibited upward distortion to the left horizontal stabilizer and elevator tip. There were weeds spread over the top and trailing edge surfaces of the horizontal stabilizer. The engines and all major sections of the airplane remained attached. The right wing was deformed up and aft, exhibiting chordwise and upward crushing, rupturing both fuel tanks. A 3 foot section of the right wingtip was located 24 feet aft of the aircraft tail. The left wing was intact and exhibited crushing on the underside. Both engines broke away from their mounts and remained attached to their respective wings by cables and lines. The cockpit overhead, fuselage and windshield were broken open immediately forward of the spar carry though structure. The nose cone was crushed on the bottom and right side, and separated from the fuselage. The control yokes were both broken from the control column. No shoulder harnesses were installed in the aircraft.

Continuity was established for all flight controls. Trailing edge flap actuator rod extensions were 1-5/8", which corresponds to a retracted position. All three landing gear were extended.

Neither propeller was feathered. The right propeller exhibited slight leading edge polishing and chordwise dirt streaks. There was slight forward bending of one right prop blade at midspan with the tip curled aft. The other right prop blade was bent aft under the engine. The left propeller showed no damage on one blade with the other blade bent aft under the engine. Both left propeller blades had spanwise dirt streaks.

Both left and right main fuel strainers were clean and unobstructed. Both left and right engine carburetor inlet screens were clean and unobstructed. The fuel lines to the right engine were separated at the firewall. Fuel was found in the low sections of the lines from between the mechanical and electric fuel pumps and the carburetor. When air was blown through the right engine fuel supply line at the fuel selector valve manifold, a clear blue liquid was expelled from the broken fuel lines near the right wing firewall. Both right wing fuel tanks were ruptured, and the ground under the right wing was fuel soaked. All fuel lines to the left engine were intact. Removing the fuel lines at the electric and engine driven fuel pumps revealed no liquid. Removal of the fuel line at the left engine carburetor revealed no liquid. The left engine carburetor was intact. When air was blown through the lines from the left engine fuel selector valve, no liquid was expelled at the disconnected firewall lines to the left engine. Both left wing tanks were intact, and the left main tank was visually inspected full by a Federal Aviation Administration inspector shortly after the accident. Eighteen (18) hours after the accident, the NTSB investigator observed the left main tank to be 1/2 full of a clear blue liquid. The left auxiliary tank was visually inspected empty both times.

MEDICAL AND PATHOLOGICAL

An autopsy was performed on both occupants by the St. Louis County Medical Examiner's Office, St. Louis, Missouri at 2200 hours central standard time on February 6, 1994. The cause of death in both cases was cited as blunt trauma resulting from an air crash. Toxicological test results are enclosed.

TESTS AND RESEARCH

Air pressure testing showed the fuel lines from the fuel tanks to the fuel selector valves were intact. Air pressure testing indicated the fuel lines from the selector valves to the engine firewalls were intact. Air pressure testing of the fuel system plumbing prior to disassembly of the fuel selector valves showed the primary flow path to the left engine, regardless of fuel selector valve handle position, was to/from the Left Aux tank. The primary fuel path to the right engine when the right fuel selector valve handle was in the Main or Aux position was from the Left Aux tank. When the right fuel selector valve handle was in the Crossfeed position, the fuel path was from the Right Aux tank.

Disassembly of both fuel selector valves (Part # 50-389002) showed that the internal valve ports were reversed 180 degrees from the indicated handle position. The handles were installed 180 degrees from the stamped arrow on the valve driver.

Disassembly of the left fuel selector valve revealed extruded packing seals in the crossfeed and auxiliary ports. These extruded seals created a 1/8" gap between the valve core with internal passages and the valve rotor with selector ports. The packing seals in the main port were intact.

According to the mechanic who installed this kit, he was unable to reattach the valve driver (Part # 96-920020-1) and handle (Part # 95-920001-79) to the valve yoke as called for in the MSB #2449 instructions. In order to reassemble the selector valve assembly, he stated he switched the left and right valve assemblies.

Subsequent investigation has shown that the Mandatory Service Bulletin kit could not be installed as depicted in the instructions (enclosed). The fuel valve driver (Part # 96-920020-1) has two distinct and different diameter lobes which only fit onto the valve yokes one way. One lobe is extended to depress a microswitch which will illuminate the MSB annunciator light. As issued in the kit, the extended lobes were 180 degrees from the desired location for installation. If the kit instructions were followed, the valve drivers could be attached, but the extended lobes would not be in a position to depress the microswitches when the valve was positioned to the "aux" position. The instructions did not call for switching the fuel valves.

ADDITIONAL DATA/INFORMATION

The airplane was released to Mr. J. A. Potchen of Aviation Underwriting Specialists, Chesterfield, Missouri, on February 16, 1994.

NTSB Probable Cause

incorrect installation of the fuel selector valves during mandatory service bulletin modification which resulted in fuel starvation to both engines and failure of the pilot-in-command to maintain aircraft control during emergency descent. A factor was inadequate quality control prior to publication of the mandatory service bulletin.