Investigation Summary
The investigation revealed a critical maintenance error involving the fuel system's non-return valves. The Blackburn Beverley's fuel system for the port wing utilized a collector box fed by four tanks. A non-return valve located between the No. 1 port tank and the collector box had been fitted backwards. During the flight, the No. 1 engine was shut down as a precautionary measure. When the crew attempted to manage the remaining power, the No. 2 engine suffered fuel starvation because the reversed valve prevented fuel from reaching the collector box from the primary supply. Although two smaller fuel tanks were available, they were not selected during the flight. The Board of Inquiry determined that the captain likely believed the engines would operate correctly from the main tanks and had no reason to suspect a mechanical blockage. The technician who installed the valve was subsequently court-martialled for negligence.
Final Conclusions
The Board of Inquiry concluded the primary cause was fuel starvation resulting from the incorrect installation of a non-return valve in the fuel system. Secondary factors included the precautionary shutdown of the No. 1 engine and the fact that auxiliary fuel tanks, which might have provided a limited supply, were not selected. The investigation led to a significant redesign of aircraft components to prevent similar maintenance errors.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Fuel Non-Return Valve
A valve designed to allow fuel flow in only one direction; its reversed installation blocked the fuel supply to the port engines' collector box.
Bristol Centaurus 173 Engines
The aircraft was powered by four of these 18-cylinder radial engines; the two port engines (No. 1 and No. 2) lost power during the accident sequence.
Interesting Facts
- 01The aircraft was carrying members of 47 and 53 Squadrons, RAF Police, and Military Working Dogs.
- 02A non-return valve in the fuel system was found to have been installed in reverse.
- 03The crash resulted in 20 total fatalities: 15 passengers, 3 crew members, and 2 civilians on the ground.
- 04Four occupants survived the crash: two crew members and two passengers.
- 05The technician responsible for the valve installation was reprimanded following a court-martial.
- 06The aircraft was only one year old, having been manufactured in 1956.
Safety Actions & Advisories
Valve Redesign
The non-return valve was redesigned with different thread sizes at each end to make incorrect installation physically impossible.
Airworthiness Design Standards Update
Design standards were changed to ensure that similar critical components cannot be assembled in the wrong orientation (Poka-yoke principle).