HOUSTON, TX, USA
N4005A
Beech BE-95-B55
The pilot did not perform an aircraft runup and proceeded to takeoff. Numerous witnesses observed the airplane pitch up to a 70 to 80-degree nose high attitude upon liftoff. The witnesses then observed the nose of the airplane momentarily pitch nose down slightly and immediately pitch nose high again. They then reported observing the airplane roll to the left and impact the ground in a nose low, left wing low attitude. Shortly after impacting the ground, a fire erupted. Examination of the wreckage revealed that the pilot had failed to remove the control lock pin from the control column. A safety alert, service instruction, and mandatory service bulletin were issued by the aircraft manufacturer, which dealt with control lock awareness and a control lock modification. The pilot/aircraft owner did not comply with the service instruction and mandatory service bulletin, nor did he have the original control lock assembly installed. A conservative weight and balance computation indicated that the pilot loaded the airplane beyond the airplane's certificated maximum gross weight and aft center of gravity limitations. An autopsy of the pilot revealed that he had suffered from an 'acute myocardial infarct' prior to the airplane impacting the ground.
HISTORY OF FLIGHT On May 12, 2000, at 1151 central daylight time, a Beech BE-95-B55 twin-engine airplane, N4005A, was destroyed when it impacted terrain following a loss of control during takeoff from the William P. Hobby Airport, Houston, Texas. The instrument rated private pilot, who was the registered owner and operator of the airplane, and his 5 passengers were fatally injured. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight was originating at the time of the accident and was destined for Galliano, Louisiana. At 0739, the pilot contacted the San Angelo Flight Service Station and obtained a weather briefing and filed three IFR flight plans. The three flight plans were: first from San Marcos, Texas, to Ingleside, Texas; second from Ingleside, Texas, to Houston, Texas; and third from Houston, Texas, to Galliano, Louisiana. The third flight was initiating after the last passenger was picked up in Houston. According to ramp personnel in Houston, the pilot requested a "quick turn" between 1115 and 1130, and signed a fuel ticket requesting to top off the inboard fuel tanks and add 10 gallons of fuel to each outboard fuel tank. At 1146:24, ground control cleared the airplane to taxi to runway 22. At 1147:46, ground control asked the pilot if he would "need a runup or [will] you be ready when you get there?" The pilot responded that he would be ready for takeoff when he reached runway 22. At 1149:04, the airplane was cleared to taxi into position and hold on runway 22. The pilot acknowledged the clearance. At 1150:03, the airplane was cleared for takeoff. According to numerous witnesses, located on or near the airport at the time of the accident, the airplane lifted off and pitched up to approximately 70 to 80-degree nose high attitude. The witnesses reported that the nose of the airplane momentarily pitched down slightly and immediately pitched "very nose high." The airplane then rolled to the left, and subsequently impacted the ground in a nose low, left wing low attitude. The witnesses added that the airplane ignited into flames approximately 60-90 seconds after ground impact. The witnesses stated that they heard "both engines producing power" during the event. PERSONNEL INFORMATION The private pilot was issued an instrument airplane rating on October 12, 1979. On October 22, 1981, the pilot obtained a multi-engine airplane rating. The pilot's last biennial flight review was completed on November 21, 1999, in the accident airplane. The pilot stopped logging flights in his logbook in 1992. According to an insurance application filled out approximately one year prior to the accident, the pilot had accumulated a total of 3,000 flight hours, of which 740 hours were in the same make and model as the accident airplane. The pilot was issued a third class medical certificate on January 25, 2000, with the limitation "holder shall wear corrective lenses." On his last FAA medical application dated January 25, 2000, the pilot reported having accumulated 4,111 total flight hours. AIRCRAFT INFORMATION The 6-seat airplane was manufactured in 1970 by Beech Aircraft Corporation. The airplane was maintained in accordance with an Approved Aircraft Inspection Program (AAIP), which consisted of a total of 4 inspections accomplished at 3-month intervals. According to the aircraft maintenance records, the accident airplane underwent its 4th inspection, which met annual inspection requirements, on November 30, 1999, at an aircraft total time of 3,276.4 hours. The right engine, a Teledyne Continental IO-470-L(24B) engine, was remanufactured and zero-timed on September 18, 1997, and was installed on the accident airplane on November 21, 1997 at an aircraft total time of 3,052.7 hours. The right engine underwent its last 100-hour inspection on November 30, 1999. The left engine, a Teledyne Continental IO-470-L(24B) engine, was remanufactured and zero-timed on March 1, 1996, and was installed on the accident airplane on March 25, 1996, at an aircraft total time of 2,831.2 hours. The left engine underwent its last 100-hour inspection on November 30, 1999. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in a grassy area 140 feet south of taxiway Kilo, between taxiway Mike and runway 12L/30R. The airplane came to rest upright on a magnetic heading of 095 degrees, with the bottom side of both engines embedded in the mud. The empennage, aft of the cargo area, was bent to the left; however, it remained attached to the fuselage. The left side of the airplane, the cockpit, and sections of the right wing sustained fire damage. The top of the fuselage was split open, and all but a few travel bags had been thrown from the fuselage. The forward fuselage exhibited crushing in the aft direction. Flight control continuity was confirmed from the cockpit to the flight control surfaces. Both of the aileron bell cranks were broken; however, the control cables remained attached to their respective bell crank sections. The aileron trim tab actuator measured 1.5 inches, which corresponded to a 1.13-degree tab down position. The elevator trim tab actuators measured 0.87 inches, which corresponded to a 2.7-degree tab up position. The rudder trim tab actuator measured 3.87 inches, which corresponded to a 0-degree deflection of the rudder trim tab. The left and right flap actuators measured 1.6 and 1.4 inches respectively. The range for the flap actuators is 1.72 inches for flaps up and 6.22 inches for flaps down. The landing gear actuator was found in the extended position. The engines remained attached to the wings and both displayed crushing in an upward and aft direction. Both propellers were found separated from and adjacent to their respective engines. The propellers were partially embedded in the dirt. The left engine crankshaft was found fractured just aft of the propeller flange, and the left propeller remained attached to the forward section of the engine crankshaft. The right propeller separated from the engine at the propeller flange. Examination of the airplane revealed that a flight control lock was found installed in the cockpit's flight control column. The control lock pin was found bent aft. The control column hangar assembly hole, in which the control pin was inserted, was broken out. The throwover control yoke was found positioned to the left side. The control yoke was found separated from the control column and both the left and right control yoke horns were found separated from the yoke. During the wreckage examination, twelve, 10-pound rectangular weights were found in the nose baggage compartment. Approximately 40 pounds of personal effects were returned to the passengers' and pilot's families at the accident site. The remainder of the personal effects stayed with the aircraft for transport to Air Salvage of Dallas, Lancaster, Texas, for further examination. METEOROLOGICAL INFORMATION At 1150, the Houston Hobby Airport's weather observation facility reported the wind from 100 degrees at 8 knots (with wind variable from 170 to 230 degrees), visibility 10 statute miles, ceiling broken at 2,500 agl and 25,000 feet agl, temperature 84 degrees Fahrenheit, dew point 73 degrees Fahrenheit, and altimeter setting of 29.84 inches of mercury. PATHOLOGICAL INFORMATION An autopsy was conducted on the pilot by the Harris County Medical Examiner. According to the medical examiner's report, the pilot died as a result of an "acute myocardial infarct followed by massive blunt force trauma." Toxicology tests for carbon monoxide, cyanide, ethanol, and drugs revealed that phenylpropanolamine was detected in the liver. Phenylpropanolamine is a drug commonly used in over-the-counter nasal decongestants and/or diet aides. Discussions with the pilot's family revealed that the pilot went to bed approximately 2100, the night before the accident. The pilot's wife stated that the pilot awoke approximately 0730, on the morning of the accident, ate breakfast, and left for the flight. She added that he did not mention feeling ill that morning. TEST AND RESEARCH An examination of the airplane wreckage was conducted at Air Salvage of Dallas, Lancaster, Texas, under the supervision of the NTSB investigator-in-charge (IIC). During the examination, the NTSB IIC removed the personal effects from the wreckage and had them weighed. The weight of the personal effects was 128 pounds. A weight and balance calculation was performed by a representative of the aircraft manufacturer. The calculation was based on the personal effects found in the wreckage, the weights found in the nose baggage compartment, the weights of the pilot and passengers, and the weight of the known fuel quantity onboard the airplane at the time of the accident. The seating position of the passengers at the time of the accident was uncertain, therefore in the weight and balance calculation, the passengers were loaded with the heaviest passengers in the front and the lightest passengers in the rear of the aircraft. In the calculation, the personal effects were distributed between the forward and aft baggage areas. The calculations resulted in a gross weight of at least 5,461.65 pounds, and a center of gravity of 87.00 inches. The certificated maximum gross weight of the BE-95-B55 was 5,100 pounds, and the center of gravity limits were 80.0 inches to 86.0 inches. ADDITIONAL INFORMATION The aircraft's original control lock consisted of a control column pin, a securing clip, a throttle guard, and a rudder lock pin. The control pin was inserted into the control column hangar assembly hole and a hole in the lower side of the control column, and the securing clip wrapped over the control column to keep the control pin in place. Attached through the pin was a cable. On one end of the cable, a red throttle guard was attached. On the other end of the cable, a rudder lock pin was attached. Examination of the control lock found at the accident site revealed that it did not have the cable, rudder lock pin, and throttle guard, which the original manufacturer's control lock assembly had. The control lock found at the accident site consisted only of a pin, which was inserted into a hole in the lower right side of the control column, and a curved clip, which wrapped around the control column to secure the pin in place. The control lock found at the accident site did not match the control lock specified by the approved parts catalog. In January 1972, Beech Aircraft Corporation issued Executive Airplane Safety Communique No. 1, which was a safety reminder to "be sure control locks are removed prior to takeoff." This Safety Communique was issued after 23 accidents involving control locks occurred (in airplanes manufactured by 10 different manufacturers). The Safety Communique recommended that the operators use the "complete lock," which consisted of rudder pedal and control yoke locks and throttle guards; check the control lock during pre-flight; activate the flight controls through their complete travel; and do not use a "make-shift" control lock. In June 1974, Beech Aircraft Corporation issued Service Instruction No. 0659-155, Rev. 1, which recommended a modification of the control lock installation as a way to provide "additional indication to the pilot that the control gust lock is installed." The compliance of this Service Instruction compliance was at the "owner's discretion." The Service Instruction called for the relocation of the control lock hole on top of the control column, and 2 inches aft of the original control lock hole. In addition to the control lock hole relocation, a new control lock assembly was to be used. When the Service Instruction is complied with and the control lock is installed, the control column would be placed in a forward (nose low) position and the control yoke would be placed 12 degrees to the right (right wing low). In November 1998, the Service Instruction (No. 0659-155, Rev. 1) was converted to a Mandatory Service Bulletin (SB 27-3205) by the Raytheon Aircraft Company (formerly Beech Aircraft Corporation). According to the Mandatory Service Bulletin, the "modified/replaced control lock will prevent throttle advancement with the control surface pin installed, make the properly installed lock impossible to overlook, and locks the flight control surfaces in positions which preclude rotation." Review of the aircraft maintenance records and aircraft wreckage revealed that the aforementioned Safety Communique, Service Instruction, and Mandatory Service Bulletin were not complied with. The aircraft wreckage was released to the owner's representative on August 7, 2000.
the loss of control on takeoff as a result of the pilot's failure to remove the flight control lock due to his inadequate preflight inspection. A contributing factor was the pilot exceeding the aircraft's certificated maximum weight and balance limitations.
Source: NTSB Aviation Accident Database
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