DCA91MA052

NTSB accident investigation · Embraer 120 · Eagle Lake, TX · September 11, 1991

Accident · FatalClass 1 · MajorFinal report
Date
September 11, 1991, 10:03 local (15:03 UTC)
Place
Eagle Lake, TX
Injuries
14 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N33701Embraer 120
Weather
Visual (VMC) · Day
Status
Completed · report December 9, 1993
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19910911039219A
Case key
10966

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

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Probable cause

The failure of Continental express maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures for the airplane's horizontal stabilizer deice boots that led to the sudden in-flight loss of the partially secured left horizontal stabilizer leading edge and the immediate severe nose-down pitchover and breakup of the airplane. Contributing to the cause of the accident was the failure of Continental express management to ensure compliance with the approved maintenance procedures, and the failure of the FAA surveillance to detect and verify compliance with approved procedures. (NTSB report AAR-92/04)

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionDescent - normal
Horizontal stabilizer surface - not securedCause
Maintenance - improperCompany maintenance personnelCause
Inadequate surveillance of operationCompany/operator mgmtFactor
Inadequate surveillance of operationFaa(organization)Factor
Horizontal stabilizer surface - separation
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The airplane broke up in flight while descending from FL240. The horizontal stabilizer, or top of the t-type tail, had separated from the fuselage before ground impact. Examination revealed that the 47 screw fasteners that would have attached the upper surface of the leading edge assembly for the left side of the horizontal stabilizer were missing. They had been removed the night before during scheduled maintenance. Investigation revealed that there was a lack of compliance with the faa-approved general maintenance manual procedures by the mechanics, inspectors, and supervisors responsible for assuring the airworthiness of the airplane the night before the accident. In addition, routine surveillance of the Continental express maintenance department by the FAA was inadequate and did not detect deficiencies, such as those that led to this accident.

Factual narrative

See national transportation safety board blue cover report aar- 92/004.

Aircraft

Registration
N33701
Reported as
Embraer 120
Category
Airplane
Serial number
120-L77
Airframe hours
7,229
Engine
P&W, turbo prop
Damage
Destroyed
Fire
Both
Flight
Part 135
Operator
Continental Express
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 10, 1991
Departed
LRD · Laredo, TX
Destination
IAH · Houston, TX
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
29
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
4,243 total · 2,468 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 7 knots
Visibility
6 statute miles
Lowest ceiling
3,000 ft broken
Temperature
82 °F, dew point 73 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

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

Other investigations on N33701 · 1

Matched to the same aircraft by N-number and date.