CEN11IA280

NTSB incident investigation · Beech 90B · Chickasha, OK · April 11, 2011

Incident · No injuriesIncident investigationFinal report
Date
April 11, 2011, 10:15 local (15:15 UTC)
Place
Chickasha, OK
Injuries
4 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N37OUBeech 90B
Defining event
Approach-VFR pattern downwind: Aircraft structural failure
Weather
Visual (VMC) · Day
Status
Completed · report July 12, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Oklahoma City FSDO
Case key
78839

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The mechanic's improper installation of the aileron.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Wing structure: aileronsAircraft › Aircraft structures · Incorrect service/maintenanceAll aircraft: 12 casesProbable cause
Wing structure: attach fittings (on wing)Aircraft › Aircraft structures · Incorrect service/maintenanceAll aircraft: 21 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelAll aircraft: 1,386 casesProbable cause
Wing structure: aileronsAircraft › Aircraft structures · Related maintenance infoAll aircraft: 12 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Aircraft structural failureApproach-VFR pattern downwindAll aircraft: 290 casesDefining event

Analysis

The certified flight instructor (CFI) reported that the airplane was on a downwind leg for landing when a pilot-rated passenger who was sitting in the cabin told him that the right aileron was partially separated from the airplane. The CFI took control of the airplane and landed it uneventfully. The post incident inspection of the airplane revealed that the two inboard aileron hinges were separated from the airframe. The screws (8 screws, 4 upper, 4 lower) which attached the aileron to the aileron hinge points were seated in the aileron skin, but did not screw into the corresponding nut plates on the aileron hinge points. The aileron was not damaged so a mechanic attached the aileron properly to the aileron hinge points and the airplane was returned to service. Maintenance records indicated that the airplane had undergone a phase inspection 10 days prior to the incident. During the phase inspection, the right aileron was removed to repair some light surface corrosion and was reinstalled on the airplane. The incident occurred 5.3 hours after the phase inspection was performed. Eight years prior to the accident, the aircraft manufacturer issued a communique which stated that their technical support department had received reports that during aileron installation, screws missed the nut plates on the aileron hinge points. It stated that this condition can go unnoticed.

Factual narrative

On April 11, 2011, at 1015 central daylight time, a Beech 90B, N37OU, sustained minor damage when two of the three right aileron hinges became disconnected while the airplane was in the traffic pattern at the Chickasha Municipal Airport (CHK), Chickasha, Oklahoma. The certificated flight instructor (CFI) took control of the airplane, made a left turn from the downwind leg, and made an uneventful landing on runway 35 (5,101 feet by 100 feet, concrete) at CHK. The CFI, the commercial student pilot, and two pilot-rated passengers were not injured. The airplane was registered to and operated by the University of Oklahoma as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed at the time of the incident. The flight departed a 0915 on a local instructional flight, and no flight plan was filed. Maintenance records indicated that the airplane had undergone a phase inspection on April 1, 2011. During the phase inspection, the right aileron was removed to repair some light surface corrosion and was reinstalled on the airplane. The incident occurred 5.3 hours after the maintenance was performed. The post incident inspection of the airplane by the operator's mechanic revealed that the two inboard aileron hinges were separated from the airframe. The mechanic determined that the screws (8 screws, 4 upper, 4 lower) which attached the aileron to the aileron hinge points were seated in the aileron skin, but did not screw into the corresponding nut plates on the aileron hinge points. The aileron was not damaged so the mechanic attached the aileron properly to the aileron hinge points and the airplane was returned to service. The Beech King Air 90 Series Maintenance Manual, Chapter 27-10-00-201, P/N 90-590012-13, Revision B22, Nov. 2010 provides procedures for aileron installation. Step B of the procedure states, "Carefully align the three hinges with the aileron and install the bolts in each hinge bracket and the aileron." Step C of the procedure states, "Pull on the aileron straight away from the wing. If any movement is detected, carefully check the bolt installation." In 2003, the Raytheon Aircraft Company issued King Air Communique No. 2003-13. The communique stated in part the following: "Raytheon Aircraft Company Technical Support has received reports that during aileron installation the MS27039-1-11 screws missed the nut plates on the aileron hinge points. This condition can go unnoticed. Some operators have painted witness marks on the aileron hinge brackets to give technicians a visual cue that installation is not correct." The National Transportation Safety Board (NTSB) is currently investigating a similar accident that occurred on February 15, 2011, near Des Moines, Iowa (CEN11LA192). In that accident, the aileron of a Beech E-90 departed from the airplane in-flight during a "return for operation" flight. The airplane had recently undergone maintenance to the aileron. The pilot reported that theairplane was "very controllable" and the airplane was landed without incident.

Aircraft

Registration
N37OU
Reported as
Beech 90B
Category
Airplane
Serial number
LJ-1428
Airframe hours
2,789
Engine
P&Wc PT-6A-21, 550 horsepower, turbo prop
Damage
Minor damage
Flight
Instructional · Part 91
Operator
University of Oklahoma, Dept of Aviation
Registered owner
Board of Regents, University of Oklahoma
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · April 1, 2011 · 5 hours before
Departed
OUN · Norman, OK
Destination
OUN · Norman, OK
Airport
CHK · Chickasha Municipal Airport, runway 35, 5,101 × 100 ft, concrete

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
21
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
December 8, 2010
Seat
Left
Flight hours
209 total · 1 in this make and model · 163 as pilot in command · 1 in the last 90 days · 1 in the last 30 days · 1 in the last 24 hours
Role
Flight instructor
Age
31
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 17, 2010
Seat
Right
Flight hours
4,152 total · 679 in this make and model · 4,083 as pilot in command · 32 in the last 90 days · 22 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 19 knots, gusting 29
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 45 °F
Altimeter
30.06 inHg
Observed at
CHK

Docket · 9

The files NTSB released with the investigation on May 2, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.5 MB in all.