Aviation Accident Summaries

Aviation Accident Summary FTW00LA047

BIG LAKE, TX, USA

Aircraft #1

N991Q

Beech BE-95A

Analysis

The pilot-in-command (PIC), who was in the right seat, observed that the windsock at the non-towered airport was 'approximately half erect, showing a west/southwest wind.' The PIC reported that he and the left-seat pilot, who were both commercial/flight instructor pilots, made a decision that the PIC would land the airplane. The PIC stated that 'we completed the before landing checklist.' The PIC reported that the airplane touched down on the centerline of runway 16, and a 'strong gust from the west took us off centerline and nearly made us wingover.' The PIC aborted the landing, applied full throttle, and retracted the gear and flaps. Subsequently, the stall warning horn sounded, the left wing struck a power line, and the airplane entered an uncontrolled descent to the left and impacted a carport, residential fences, and trees before coming to rest. The post-impact fire destroyed the airplane. The PIC reported 4 hours of flight time in the accident make and model of airplane. The wind was reported, by a witness/pilot, variable from the west/southwest and gusty. Airmet Tango was valid at the time of the accident for occasional moderate turbulence below 8,000 feet msl. There was no record that the pilots had requested an in-flight weather briefing during the cross-country flight. Both fuel selectors were found in the auxiliary fuel tank position. According to the airplane owner's manual and the checklist, auxiliary fuel tanks are to be used during level flight only. During the investigation, there were no mechanical discrepancies or anomalies found that would have contributed to the accident.

Factual Information

HISTORY OF FLIGHT On December 17, 1999, at 1600 central standard time (CST), a Beech BE-95A, multiengine airplane, N991Q, struck obstacles and terrain during an aborted landing at the Reagan County Airport, near Big Lake, Texas. The airplane, owned by a private individual, was operated under 14 Code of Federal Regulations Part 91. The two commercial pilots were seriously injured, and the post-impact fire destroyed the airplane. Visual meteorological conditions prevailed for the personal cross-country flight, and a flight plan was not filed. The flight originated from El Cajon, California, and was en route to Gulfport, Mississippi. Following a refueling stop, the flight departed Santa Teresa, New Mexico, at 1315. The two pilots shared the responsibility for the preflight following the refueling at the Dona Ana County Airport, Santa Teresa, New Mexico. No anomalies were noted during the preflight, start-up, run-up, or subsequent flight to Big Lake, Texas. During the initial en route phase, checklist items were accomplished via a cockpit resource management (CRM) format, whereby, the pilot not flying (PNF) would call out the checklist items and the pilot flying (PF) would confirm completion of the checklist item. During the initial portion of the flight from Santa Teresa, the PF was the left-seat pilot, and the PNF was the right-seat pilot. En route the pilot responsibilities were switched and the right-seat pilot became the pilot-in-command (PIC) and assumed the PF responsibilities for the flight. Approximately 20 miles from the Reagan County Airport, Big Lake, Texas, the PIC (right-seat pilot) cancelled the flight following services with Fort Worth Air Route Traffic Control Center (ARTCC). The PIC observed that the windsock at the airport was "approximately half erect, showing a west/southwest wind." Another airplane was on final for runway 16. The PIC reported that the two pilots discussed landing the airplane, and the decision was made that the PIC would land the airplane. The PIC further stated that "we completed the before landing checklist" and prepared for landing the airplane on runway 16. The PIC reported that the airplane touched down on the centerline of runway 16, approximately 50 to 75 feet beyond the threshold, and after the nose wheel touched the runway, a "strong gust from the west took us off centerline and nearly made us wingover." The PIC aborted the landing and applied full throttle. The PIC retracted the gear and flaps. Subsequently, the airplane began to lose climb performance, the airspeed began to decrease, the control became mushy, and the stall warning horn sounded. The ailerons became "ineffective and the left wing was low causing us to continue turn." To avoid a building, the PIC pulled "up with the remaining airspeed." The airplane sank and struck a power line with the left wing, and the wires "ripped through the wing causing a massive explosion." The airplane "yawed to the left and we cart wheeled before impact with the ground." A pilot witness, who had just landed his airplane at the airport, observed the accident airplane in the traffic pattern and reported that it appeared to be "too high upon turning base to final, and the crosswind caused the aircraft to overshoot the final course." The witness noted that the airplane's landing gear and flaps were extended. Subsequently, this witness observed the airplane yawing to the left of the runway in a "steep angle climb attitude" approximately 300-500 feet east of the runway. The landing gear and flaps were retracted and the pitch attitude was lowered; however, the airplane continued to yaw to the left. Near the power lines that paralleled the runway, approximately 700 yards east of the runway centerline, the airplane was observed to "pitch up slightly." The airplane struck the power lines and a pole. Following contact with the pole, the left wing was "engulfed in flames" as the airplane continued to descend. Another witness observed the airplane at a "slow speed and not able to gain altitude over maybe 50 feet." This witness reported the wind was variable from the west/southwest and gusty. Local authorities and the FAA inspector, who responded to the accident site, reported that the airplane impacted a carport, residential fences, and trees before coming to rest. PERSONNEL INFORMATION The FAA records reviewed by the NTSB investigator-in-charge (IIC) revealed that the PIC (right-seat pilot) was a commercial pilot with single and multiengine land, and instrument airplane ratings. The PIC obtained the multiengine land rating on March 25, 1999. On April 6, 1999, he obtained the multiengine flight instructor rating. Subsequently, he added the instrument rating to his flight instructor certificate. On the NTSB Form 6120.1/2, the PIC reported that he had accumulated approximately 400 hours of flight time, which included 300 hours in multiengine airplanes. He reported 4 hours of flight time in the BE-95A airplane. He reported that he had given 200 hours of multiengine instruction; however, none of the instruction was in the BE-95A airplane. According to the NTSB Form 6120.1/2, the PIC held a first class medical certificate issued April 12, 1999, without limitations or waivers. The FAA records reviewed by the NTSB IIC revealed that the PNF (left-seat pilot) was a commercial pilot with single and multiengine land, and instrument airplane ratings. The PNF obtained his multiengine rating and multiengine flight instructor rating in November 1999. He held a first class medical certificate issued November 12, 1999, without limitations or waivers. On the NTSB Form 6120.1/2, the PNF reported 343.2 hours of total flight time, which included 175 hours in multiengine airplanes. He reported 30.1 hours of flight time in the BE-95A airplane. AIRCRAFT INFORMATION The aircraft (S/N TD-496) was manufactured in 1961, and was issued a FAA standard airworthiness certificate on November 3, 1961. On November 15, 1977, the hobbs meter was replaced (old meter reading 2,080.4 hours). The airplane was registered to the current owner in September 1999. The last recorded annual inspection, dated August 19, 1999, was performed at 2,535.6 hours (hobbs meter 455.6 hours) total aircraft time on August 17, 1999. At the time of this inspection, the left engine (Lycoming IO-360-B1A, serial number L-240-51) had accumulated 1,407.9 hours since the major overhaul in 1965. The right engine (Lycoming IO-360-B1A, serial number L-193-51) had 1,829.2 hours since the major overhaul in 1964. The propellers (Hartzell HC92ZK-2B) were inspected at the last annual inspection with no discrepancies noted. At the time of this inspection, the propellers had accumulated 197.4 hours since the last propeller overhaul in February 1997. In December 1997, the Bendix magnetos, serial numbers 769973, 769258, 789737, and 786988 were disassembled, cleaned, inspected, and repaired. In March 1999, the Simmons fuel injector pump, part number 530002-3, serial number V18742, was overhauled, flow tested, and reinstalled on the left engine. METEROLOGICAL INFORMATION The National Weather Service (NWS) area forecast outlook for southwest Texas in the vicinity of Big Lake reported visual meteorological conditions. Airmet Tango was valid at the time of the accident for occasional moderate turbulence below 8,000 feet msl. The NWS surface observation reporting stations along the cross-country route and in the quadrants surrounding the Big Lake Airport included Marfa (MRF), Guadalupe Pass (GDP), Fort Stockton (FST), Wink (INK), Odessa (ODO), Midland (MAF), and San Angelo (SJT). These stations reported the following: MRF at 1555, wind 280 at 25 knots; GDP at 1553 wind 210 at 20 knots gusting to 33 knots; FST at 1553, wind 300 at 15 knots gusting to 24 knots; INK at 1550, wind 300 at 17 knots gusting to 23 knots; ODO at 1553, wind 260 at 12 knots; MAF at 1556, wind 280 at 12 knots; SJT at 1556, wind 240 at 15 knots. The NWS forecasted winds at MAF (59 nautical miles west/northwest of Big Lake) by 1624, to be from 340 degrees at 16 knots gusting to 26 knots. COMMUNICATION Air Traffic Control data revealed that at 1334, the aircraft was 11 nautical miles east (098 degree radial) of the El Paso VOR, in radio contact with Albuquerque (ABQ) ARTCC, and receiving VFR flight following via the assigned transponder code of 2647. The average en route altitude was 9,500 feet msl with an average speed of 170 knots. At 1543, the airplane was 22 nautical miles east (070 degree radial) of the Fort Stockton VOR. En route, the aircraft was handed off to Houston ARTCC. At 1548, the pilot reported to Houston ARTCC that the flight was leaving 9,500 feet msl for 5,500 feet msl. At 1556, the airplane was descending through 7,000 feet msl ( North 31.07 degrees; West 101.51 degrees) when the pilot cancelled the VFR flight following with Houston ARTCC. According to the San Angelo Flight Service Station personnel, there was no record that the flight had requested an in-flight weather briefing. AERODROME INFORMATION The Reagan County Airport (E41), at an elevation of 2,704 feet, is a non-towered airport. The hard surface (asphalt) runway 16-34 is 4,031 feet long and 50 feet wide. Runway data indicates brush at the approach end of runway 16. The Common Traffic Advisory Frequency (CTAF) is 122.8 Megahertz. Weather information may be obtained en route via the San Angelo Flight Service Station flight watch frequency 122.2 Megahertz or the remote communication outlet frequency 122.4 Megahertz. The Fort Worth ARTCC frequency is 133.7 Megahertz. WRECKAGE AND IMPACT INFORMATION The FAA inspector, who responded to the site, reported the wreckage distribution energy path was along a magnetic heading of approximately 110 degrees with the final resting site east of the airport between two homes located at 509 and 511 North Mississippi Street. The first point of impact was a utility pole, which was broken off at approximately 25-30 feet agl. Utility personnel stated that the three phase electrical power lines and transformer carried by the utility pole were severed or knocked down. Found near the pole was an inboard portion of the aircraft's left aileron. No physical evidence of sooting or thermal damage was found on the aileron. Approximately 45 yards from the utility pole, two of the three secondary power distribution lines providing residential service were found down. The outboard portion of the left wing was found lying on the ground beyond the distribution lines and approximately 20 feet prior to the main wreckage. The main wreckage came to rest on a heading approximately 180 degrees from the energy path and approximately 87 yards from the initial point of impact. A residential fence, a carport, and a parked vehicle were found damaged. The FAA inspector found evidence of fuel in all the fuel tanks, except the left outboard tank. The integrity of the left outboard fuel tank was compromised. He noted and documented in photographs that both fuel selectors were found selected to the auxiliary fuel tank positions. The landing gear was found in the retracted position, and the flaps "appeared to have been retracted." The control yoke was the "throw-over" style yoke and was found in the right hand position. The FAA inspector verified the left engine gear train continuity by rotating the propeller and viewing the accessory gears through the left magneto mounting hole. The left propeller high pitch stops exhibited gouges. The FAA inspector did not rotate the right engine. MEDICAL AND PATHOLOGICAL INFORMATION Aviation toxicological testing was neither requested nor performed. SURVIVAL ASPECTS Both pilots exited the airplane, and local residents risked their lives as they immediately helped the injured away from the burning wreckage. Various local authorities assisted in preparing the injured for transport to the hospital. Firefighters achieved control of the fire. Site security was established and the Federal Aviation Administration (FAA) at Lubbock, Texas, was notified. TEST AND RESEARCH The airframe and engines were examined in January 2000, at Lancaster, Texas, under the surveillance of the NTSB IIC. The wing flaps were found in the up position, and both main landing gears were in the wheel wells with their inboard doors closed over the wheels. Continuity of the landing gear system was confirmed by cranking the gear out of the wheel wells utilizing the emergency gear extension handle. Flap position was confirmed in the retracted position by measurement of the actuators. Flight control continuity was confirmed to all flight control surfaces from the cockpit. The elevators were attached to their respective horizontal stabilizers, and the elevator trim was measured and found to be in a three-degree tab down, or elevator up, position. The throw-over control arm was found on the right side, and the yoke was found melted in the right front seat. Both fuel selectors were found in the auxiliary tank position. Both engines, Lycoming model IO-360-B1A, (left engine serial number L-240-51; right engine serial number L-193-51) and the accessories that were not destroyed by the post-impact fire, were examined. Each engine crankshaft was rotated manually and there was valve action, and thumb compression on all cylinders, and continuity to each accessory case was confirmed. Both magnetos (Bendix model S4LN-204) for the left engine, produced spark at all posts when their respective shafts were rotated by hand. According to the engine representative, the right magneto shaft bearing "appeared to be worn and rough." Both magnetos (Bendix model S4LN-204) for the right engine would not produce spark when their shafts were rotated by hand. The right magneto for the right engine displayed thermal damage and its internal components were melted. The four magnetos were further examined in April 2000 at Mobile, Alabama, under the surveillance of the FAA. The manufacturer representative reported that based on their examination, "there is no evidence that these magnetos would contribute to an engine malfunction." An operational check of the fuel pump and throttle body assembly for each engine was performed at Omaha, Nebraska, in March 2000, under the supervision of an FAA inspector. According to the FAA inspector, the "operational test failed to disclose any condition to support a substantial loss of engine power." In March 2000, the propellers were examined at Lancaster, Texas. Both propellers had physical evidence of rotational scoring and twisting toward low pitch. The manufacturer representative reported that neither propeller was "feathered." He further stated that there were "no propeller discrepancies that could have precluded normal operation." ADDITIONAL DATA Beechcraft Mandatory Service Bulletin No. 2449, issued November 1993, announced the availability of kits that install an auxiliary fuel tank annunciator light. The auxiliary light will illuminate if either one of the auxiliary fuel tanks is selected when the landing gear is extended. According to the bulletin, Beechcraft Travel Air airplanes were equipped with auxiliary fuel tanks that were placarded for and limited to level flight only. If the auxiliary tanks are incorrectly selected for takeoff or go-around from landings, it is possible for air to enter the auxiliary tank outlet, leading to power interruption. Auxiliary fuel tanks are to be used during level flight only and not during takeoff or landing. According to the aircraft owner, the accident airplane was not equipped with the annunciator light. The airplane owner's manual states in part that "take-offs, climbs, and landings must be made using the main fuel cells only." The before landing check states, in part, "switch both fuel selector valves to main tanks." The before take-off check states, in part, "turn to MAIN for pre-takeoff checks." The airplane was released to the registered owner.

Probable Cause and Findings

the pilot-in-command's failure to maintain directional control of the airplane during the aborted landing. Contributing factors were the crosswind, turbulence, and the pilot's lack of total experience in the make and model of aircraft.

 

Source: NTSB Aviation Accident Database

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