CEN11LA192

NTSB accident investigation · Beech E-90 · Des Moines, IA · February 15, 2011

Accident · No injuriesLimited investigationFinal report
Date
February 15, 2011, 09:30 local (15:30 UTC)
Place
Des Moines, IA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N51DNBeech E-90
Defining event
Enroute-climb to cruise: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report July 21, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20110215001719A
Case key
78361

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

On this page

Probable cause

The improper installation of the right aileron by maintenance personnel.

Findings · 2

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBeech E-90: 1 caseAll aircraft: 371 casesProbable cause
Wing structure: aileronsAircraft › Aircraft structures · Incorrect service/maintenanceBeech E-90: 1 caseAll aircraft: 12 casesProbable cause

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.

Analysis

The airplane had recently undergone maintenance, which included an inspection of the ailerons requiring removal, reinstallation, and a functional check. Prior to the test flight, the pilot performed a pre-flight inspection of the airplane and a flight control free and correct check with no anomalies noted. While executing a turn at flight level 180, the right aileron departed the airplane. The airplane landed without further incident. Examination of the airplane revealed the inboard and middle airframe aileron hinge brackets were attached to the aft spar, intact, and showed no visible damage. The outboard airframe aileron hinge bracket was pulled and separated from the aft spar. The aileron was not located. Based on the condition of the hinge brackets, the evidence indicated the aileron bolts were not properly engaged in the aileron nut plates which caused the bolts to fall out and the aileron to depart the airplane.

Factual narrative

On February 15, 2011, at 0930 central standard time, a Beech E-90 airplane, N51DN, sustained substantial damage when the right aileron departed in-flight near Des Moines, Iowa. The airline transport pilot and pilot-rated maintenance crew member were not injured. The airplane was registered to and operated by D-W Corporation, Des Moines, Iowa. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 test flight. The local flight departed the Des Moines International Airport (DSM), Des Moines, Iowa, at 0900. The airplane had recently underwent maintenance, which included a 800-hour inspection of the ailerons requiring removal, reinstallation, and a functional check. Prior to the test flight, the pilot performed a pre-flight inspection of the airplane, and a flight control free and correct check with no anomalies noted. The airplane departed runway 13L, and the pilot made a right turn to 160 degrees. Shortly thereafter, the pilot made a right turn to 270 degrees and was cleared to flight level (FL) 180. While level at FL180 with the autopilot engaged, the pilot and maintenance crew member performed various checks with the engines and flight instruments. After completing the checks, the pilot requested a left 180-degree turn back to DSM. Air traffic control approved the turn and the pilot selected the autopilot heading switch for a left turn to DSM. Approximately 140 degrees into the turn, the autopilot jerked, stabilized, and jerked again during the turn to level off. The pilot then noticed the right aileron had departed the airplane. The airplane landed at DSM without further incident. Examination of the airplane revealed the inboard and middle airframe aileron hinge brackets were attached to the aft spar, intact, and showed no visible damage. The outboard airframe aileron hinge bracket was pulled and separated from the aft spar. The aileron was not located. The aileron is attached to each of the three hinge brackets with two upper and two lower bolts (4 total) that engage into nut plates that are mounted on the aileron. The King Air 90 Series Maintenance Manual aileron installation procedure states, in part, "Carefully align the three hinges with the aileron and install the bolts in each hinge bracket and the aileron. Pull on the aileron straight away from the wing. If any movement is detected, carefully check the bolt installation."

Aircraft

Registration
N51DN
Reported as
Beech E-90
Category
Airplane
Serial number
LW-7
Airframe hours
9,353
Engines
P&W Canada PT6A-27-28, 680 horsepower, turbo propU/A Canada PT6A-27-28, 680 horsepower, turbo prop
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
D-W Corporation
Registered owner
D-W Corporation
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · February 14, 2011 · 0 hours before
Departed
DSM · Des Moines, IA
Destination
DSM · Des Moines, IA
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Injuries
None
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 26, 2011
Seat
Left
Flight hours
15,449 total · 329 in this make and model · 13,037 as pilot in command · 60 in the last 90 days · 49 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
41 °F, dew point 32 °F
Altimeter
30.03 inHg
Observed at
DSM, 45 nm away

Docket · 7

The files NTSB released with the investigation on May 27, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.