Aviation Accident Summaries

Aviation Accident Summary CHI97FA256

ALICE, TX, USA

Aircraft #1

N41VC

Beech BE-65-A90

Analysis

The flight was part of a pre-buy inspection of the airplane. Witnesses reported the airplane did not climb more than 200 feet above ground level (agl) after takeoff. The airplane entered a shallow left turn and completed about 210 degrees of heading change before it impacted a flat field near the approach end of runway 26. Witnesses reported that the landing gear were retracted and that the engines sounded like they running at high power, but the airplane did not accelerate or climb normally. The airspeed was slow and 'mushy.' The engines' gas generator sections exhibited strong rotational scoring. The engines' power sections exhibited light rotational signatures. The left and right propellers exhibited minimal leading edge damage. Both propellers exhibited high blade angles. The secondary low pitch stops (SLPS) had been installed on the aircraft four days prior to the accident. A ground check, but no flight check, had been conducted. The SLPS sensors were found in the full aft position on the mounting bracket, not in the normal mid-range position. The SLPS control box installed on the aircraft was an updated box and was incompatible with the existing wiring.

Factual Information

History of Flight On August 12, 1997, at 1153 central daylight time, a Beech BE-65-A90, N41VC, operated by South Texas Aircraft, Inc., was destroyed when it impacted terrain 1/4 mile from the Alice International Airport, Alice, Texas. Witnesses reported that that airplane departed runway 13 but did not climb more than 200 feet above ground level (agl). The airplane entered a shallow left turn and completed about 210 degrees of heading change before it impacted a field near the approach end of runway 26. The pilot, copilot, and two passengers were fatally injured. The 14 CFR Part 91 flight departed Alice, Texas, on a local flight as part of aircraft sales pre-buy flight. Visual meteorological conditions prevailed and no flight plan had been filed. A service lineman at the airport reported seeing the pilot in the left seat of the aircraft as it taxied from the aircraft ramp to the run-up area of runway 13. A witness who was performing a pre-flight on an aircraft located at the aircraft ramp reported that he observed the airplane during takeoff until it impacted the ground. He reported that the airplane was in the run-up area of runway 13 for 10 to 15 minutes doing its ground checks. He reported that the airplane lifted off the ground about 400 feet prior to the intersection of runway 13 and runway 17 (A ground roll of about 2,800 feet). He reported that the landing gear were retracted between 20 to 50 feet agl. He reported that the engines sounded like they were running at high power, but the airplane did not accelerate or climb normally. He reported the airplane did not climb more than 200 feet agl and the airspeed was slow and "mushy." He reported the airplane entered a shallow left turn at the end of runway 13. He described the turn as a pedal turn with the wings level, and not a coordinated 5 degree angle of bank turn. He watched the airplane continue the left turn when the right wing went up and the nose of the airplane dropped to a 20 to 30 degrees nose down attitude. The airplane went behind a line of 20 foot trees and then impacted the ground. A cropduster pilot who was located about 1,200 feet from the approach end of runway 26 reported he had seen the accident. He reported that he observed the airplane in a left turn coming toward runway 26. He reported the airplane was about 40 to 50 feet agl. He reported that he thought the pilot was making a low pass over runway 26 because the landing gear were up. He reported that the engine noise was steady and normal. He reported that he saw the airplane suddenly turn with the right wing going straight up. He reported that the nose went up higher than the tail, and then the airplane went straight down impacting the ground with the left wingtip. He reported that a ball of fire went straight up after the airplane impacted the ground. Personnel Information The pilot held a commercial pilot certificate with single engine land, multi-engine land, and airplane instrument ratings. The total flight hours reported to the Federal Aviation Administration on November 11, 1995, was 17,710 hours. The pilot's logbook was not recovered and no records were produced that indicated the pilot's recent flight history. Witnesses reported that he was current and flew often during the course of operating his business, South Texas Aircraft, Inc. In 1992 the pilot had obtained an Airframe and Powerplants mechanic rating. The co-pilot held an airline transport pilot (ATP) certificate with ATP rating in multi-engine land and a commercial rating in single engine land aircraft. He held ATP type ratings in five jet aircraft. The total flight hours reported to the Federal Aviation Administration on October 17, 1996, was 35,000 hours. The pilot's logbook was not recovered. Recent records indicated he was current and qualified in a Cessna Citation 500 and a Beech Baron. Aircraft Information The airplane was a twin engine Beech BE-65-A90, King Air, serial number 242. The airplane seated 11 and had a gross weight of 9,300 pounds. The engines were 550 horsepower Pratt and Whitney PT6A-20 engines. The airplane was on an Approved Inspection Program (AIP) and was last inspected on January 24, 1997. The total airframe time was 7,249.6 hours, and had flown 5.1 hours since the last inspection. The owner of the airplane, Allegro Aviation, had purchased the airplane in 1993. On January 15, 1994, the airplane was put on an AIP maintenance inspection program. The airplane was operated and maintained by South Texas Aircraft, which was owned and operated by the pilot. On May 3, 1994, the airplane underwent a 150 hour maintenance inspection. The total time on the aircraft was 7235.5 hours. The airplane flew 14.1 hours from May 3, 1994, until the day of the accident on August 12, 1997. On November 15, 1995, the airplane was inspected as part of the AIP inspection program. The total time on the aircraft was 7243.4. It had flown 7.9 hours since the previous inspection. The president of Allegro Aviation reported that in May of 1996, a decision was made that the airplane was no longer needed and that it should be sold. He reported that he and the owner of South Texas Aircraft agreed to swap engines on their respective airplanes before the airplane was sold. On June 4, 1996, the left and right engines from the pilot owned Beech B90, King Air, N14V, serial number 411 (s/n 411), were removed from s/n 411 for installation on the Beech A90, King Air, N41VC, serial number 242 (s/n 242). The engines on s/n 411 were PT6A-20 (-20) engines, which were the model engines originally equipped on the aircraft. The engines on s/n 242 were PT6A-28 engines. The -28 engines were newer and more powerful engines. They had been installed on s/n 242 in 1992. On December 13, 1996, the -20 engines were installed on s/n 242. The total time on the airframe was 7,244.3 hours. The left and right -20 engines had 3,438 hours since new, and 206 hours since a hot section inspection had been performed. The engines scheduled TBO was 3,500 hours. The left and right propellers were overhauled in April 1996 and installed on the -20 engines on December 13, 1996. At the time of the accident, the propellers had 5.1 hours since major overhaul. On January 24, 1997, the aircraft underwent an AIP maintenance inspection. The total time on the aircraft was 7,244.5 hours. It had not flown since the engines and propellers had been installed on December 13, 1996. On January 25, 1997, the aircraft logbook entry stated, "Removed engine mounted secondary low pitch stop hardware for parts replacement." On May 28, 1997, the airplane underwent maintenance for its five year maintenance items, which included: 1. Landing gear, drag braces, actuators. 2. Gear motor and clutch assembly. 3. Flap actuators. 4. Governors: left and right primary and overspeed governors. 5. Heater, Stewart-Werner, overhauled. 6. Oxygen bottle, certification. 7. Oxygen regulator, overhauled. On May 28, 1997, the airplane also received maintenance for its IFR Certification which included the altimeters, encoders, and static system. The total aircraft time on May 28, 1997, was 7,246.8 hours. It had flown 2.3 hours since the last inspection on January 24, 1997. On June 24, 1997, the heater was repaired. The total time on the aircraft was 7,247.7 hours. It had flown 0.9 hours since May 28, 1997. On July 28, 2997, the mechanic had sent a fax to a Technical Service Representative from Raytheon Aircraft's Technical Support. The faxed transmission contained the following information concerning s/n 242: "11-6-92 -20 engines removed, -28 engines installed, engine mounted secondary low pitch stop hardware removed, all other wiring and components left intact. CURRENT -20 engines reinstalled, trying to determine what we need to reactivate secondary low pitch stop system, if possible using existing installation." The airframe logbook from s/n 411 indicated that on August 5, 1997, the secondary low pitch stop components were removed from the aircraft. The removed components that were listed in the logbook entry included the control box, relay board, and engine mounted hardware. The mechanic wrote, "System is inoperative" at the end of the logbook entry for s/n 411. On August 9, 1997, the left and right engine logbooks for s/n 242 indicated that the propeller low pitch stops and the propeller reversing function were rigged in accordance with applicable King Air 90 maintenance instructions. Also, the Airworthiness Directive (AD) 80-04-02, which required that the reverse clevis thread engagement be checked, was complied with. The total time on the aircraft was 7,249.6 hours. It had flown 1.9 hours since June 24, 1997. The August 9, 1997, s/n 242's logbook entry read, "Rigged prop low pitch and reverse in accorance with applicable instructions in King Air 90 Maintenance Manual Chapter 76. Complied with AD 80-04-02. Reverse control clevis thread engagement. Ran up, function tested satisfactorily.". On August 9, 1997, the mechanic completed a FAA Form 337 for Major Repair and Alteration. The description of work accomplished stated the following information: "8-9-98, N41VC, LJ-242, 7249.6TT. Replaced existing propeller secondary low pitch stop system with updated system removed from LJ-411. The following components were installed: 1. 50-329015-1 Switch bracket, 2 ea, engine mounted. 2. 50-329025 Switch carriage, 2 ea, engine mounted. 3. 50-329019 Arm swivel pin, 2 ea, engine mounted. 4. 50-329017 Arm assembly, 2 ea, engine mounted. 5. 1-899-15 Proximity switch, 2 ea, engine mounted. 6. 50-364431-611 Control box, fuselage mounted, C/L FS 146.00 7. No number Relay panel, fuselage mounted, C/L FS 149.00 8. MS3106A10SL4S Connector plug, prop gov, 2 ea, engine mounted. 9. M12P-LS12N Connector plug, control box Existing wiring, circuit breaker, and power lever switch were retained. Control box and relay panel were mounted with brackets to belly stringers under center isle floorboard between front and rear spar. Installed system is the same as shown for OEM systems s/n's LJ-365 thru LJ-501, See attached wiring diagram. This installation constitutes the same change as Beech Kit 90-3086-1 as referenced in Beech Service Instruction 0805-247R1. No change in system function or test procedure, no flight manual revision required." The mechanic reported that the technical information that he used for modifying the secondary low pitch stop system was the manufacturer's manuals and the Beechcraft Service Instruction No. 0805-247 Rev. 1 which was available on microfiche. The Beech Service Instruction No. 0805-247 Rev. 1 required the use of Beech Kit No. 90-3086-1 S for the parts required to accomplish the Service Instruction. The Service Instruction stated that upon its completion, a maintenance record entry must be made specifying the kit identification number and the kit serial number. There was no record that the Beech Kit 90-3086-1S was used. A kit serial number was not recorded in the aircraft's logbook. The mechanic wrote on the FAA Form 337 that, "No change in system function or test procedure, no flight manual revision required." The Beech Service Instruction No. 0-805-247 Rev. 1 stated that the FAA approved Flight Manual Supplement p/n 131543 dated February, 1979, was applicable to the modification being accomplished by the Service Instruction, and was required to be installed in the aircraft flight manual for compliance with the Service Instruction. The mechanic reported that on January 25, 1997, he had removed the secondary low pitch stop sensors and mounting brackets from the left and right -20 engines from s/n 242 and put them back on the -28 engines installed on s/n 411. The mechanic reported that the change was made in order that s/n 411 would have a complete system. However, -28 engines did not use the same secondary low pitch stop system that are required by the -20 engines. The -28 engines did not use the proximity switches used by the -20 engines to control secondary low pitch stop solenoid valves located on the propeller governor. S/N 242 flew 5.1 hours with an inoperative secondary low pitch stop system between January 25, 1997, and August 9, 1997. The mechanic reported that the secondary low stop switches needed only minor adjustments after they had been removed from s/n 411 and installed in s/n 242 on August 9, 1997. The mechanic reported that the secondary low pitch stop connector box, relays, wire connectors, and engine hardware from s/n 411 were installed in s/n 242. He reported that the original numbered wiring for the system was still in s/n -242. He reported that he installed the secondary low pitch stop connector box at FS 146 in the centerline compartment of the aircraft behind the main wing spar. He reported that he took the existing wiring that was originally installed in the aircraft and connected the wires to a connector taken from s/n 411. The aircraft, s/n 242, was reportedly ground tested after the installation of the secondary low pitch stop system. It was not flight tested prior to the accident flight on August 12, 1997. A witness reported that on the morning of the accident the nacelle fuel tanks had about 60 gallons of fuel in each tank. The wing tanks were not fueled. It was uncertain how much fuel was in the wing tanks, but they were not full. Meteorological Conditions At 1150, weather conditions reported at the Alice International Airport were VFR. The sky was clear with 15 miles visibility. The temperature was 93 degrees Fahrenheit with the dew point at 69 degrees Fahrenheit. The winds were 180 degrees at 11 knots. The altimeter was 30.06. Wreckage and Impact Information The airplane wreckage was located about 2,000 feet southeast of the approach end of runway 26 at Alice International Airport, Alice, Texas. The airplane impacted in a flat, harvested farm field on about a 280 degree heading. The main wreckage was located about 220 feet from the first impact mark, and the furthest piece of wreckage was about 280 feet from the first impact mark. The wreckage path indicated that the airplane hit the ground, left wingtip first with the airplane approximately perpendicular to the ground. Ground scars indicated that the left propeller and engine impacted the ground at about 50 to 65 feet in the wreckage path. The nose landing gear light was found 80 feet in the wreckage trail. The ground scar indicated that the right propeller and engine impacted the ground at about 80 to 95 feet in the wreckage path. The airplane skidded on it belly from about 100 feet in the wreckage path to where it came to rest in an upright position about 220 feet from initial impact. The aircraft shed parts as it slid to a stop. The aircraft sustained a post impact fire upon ground impact which burned an area from about 100 to 150 feet in the wreckage path. The left and right engines separated from the wings. The left engine and propeller were found at about 215 feet. The right engine and propeller were found at about 250 feet in the wreckage path. The majority of the fuselage and empennage were destroyed by fire. The right wing remained attached to the fuselage. The inboard half of the right wing was destroyed by fire. The left wing was destroyed by impact and had partially separated from the fuselage. The rudder and both horizontal stabilizers and elevator assemblies had separated from the empennage during the impact. Both landing gear actuators exhibited fully retracted (up) positions. The left inboard flap actuator exhibited a fully retracted (up) position. The left aileron trim tab actuator and the other three flap actuators were consumed by the fire. The cockpit instrumentation and controls were consumed by fire. The instrument panel and the right and left subpanels were consumed by fire. The remains of both power levers, propeller control levers, and condition levers exhibited full forward positions. The flap position indicator needle exhibited an UP indication. Medical and Pathological Conditions Autops

Probable Cause and Findings

loss of control due to the pilot's improper in-flight decision. A factor was the improper installation of the secondary low pitch stop system by the mechanic.

 

Source: NTSB Aviation Accident Database

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