DFW06FA019

NTSB accident investigation · Cessna 500 · Houston, TX · November 5, 2005

Accident · FatalField investigationFinal report
Date
November 5, 2005, 09:58 local (15:58 UTC)
Place
Houston, TX
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N505KCessna 500
Weather
Visual (VMC) · Day
Status
Completed · report February 26, 2007
Report
Approved by Office Director
Parties
Pratt & Whitney Canada, Federal Aviation Administration, Cessna Aircraft Company, Transportation Safety Board of Canada
FAA report
20051105034089A
Case key
62776

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 NTSB’s determination of the probable cause, and any contributing factors.

The pilot's failure to maintain directional control of the airplane resulting in an inadvertent stall/mush. Contributing factors were the unsecured passenger door and the pilot's diverted attention.

Analysis

The 4,100-hour commercial pilot lost directional control of the single-pilot twin-engine turbojet while taking off from runway 22 (7,602-feet long by 150-feet wide), and impacted the ground about 3,750 feet from the point of departure. Several witnesses reported that the airplane climbed to approximately 150 feet, rolled to the right, descended, and then struck the ground inverted. The weather was day VFR and the wind was reported from 170 degrees at 10 knots. Examination of the wreckage revealed that none of the main-entry door latching pins were in their fully locked position. The airplane's flight controls and engines did not disclose any mechanical discrepancies. The flaps were in the takeoff position and the control lock was unlocked. The pilot had not flown the airplane for over nine months because of extensive maintenance; the accident occurred on its first test flight out of maintenance. Since the pilots flight records were not found, it is unknown how much flight time the pilot had flown in the last nine months. The other airplane that the pilot owned was a Cessna 650, but witnesses stated that the pilot was only qualified as a co-pilot. Most of the maintenance records that were located were not completed; an approval for return-to-service was not found. Another airplane that had declared an emergency was on a 10-mile final when the tower cleared the accident airplane for takeoff, with no delay on the takeoff roll. No additional communication or distress calls were reported from the accident airplane. The airplane was not equipped with either a flight data recorder or a cockpit voice recorder. No anomalies were found on either engine that could have prevented normal engine operation.

Factual narrative

The factual narrative1,244 words

History of flight

On November 5, 2005, at 0958 central standard time (CST), a twin-engine Cessna 500 airplane, N505K, was destroyed upon impact with terrain following a loss of control during takeoff from the William P. Hobby Airport (HOU), near Houston, Texas. The instrument rated commercial pilot and one passenger were fatally injured. The airplane was owned and operated by the pilot. Visual meteorological conditions prevailed, and an instrument flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The local maintenance test flight was originating at the time of the accident, with Corpus Christi, Texas, as the intended destination.

Airport personnel reported that the owner of the airplane rented an office and hangar from a fixed base operator (FBO) on the east side of runway (RW) 22. Records indicate that 377 gallons of jet fuel was purchased on November 5, 2005, from the FBO's fueling vehicle about 0800; the fueling technician stated that the airplane was "topped off." Witnesses reported that the airplane had not been flown in over nine months, and was on its first flight since heavy maintenance was accomplished. Maintenance records confirmed that the airplane had not flown since January 31, 2006.

Several eyewitnesses observed the mishap. The three statements below recount their observations:

"A Citation C-500 was taking off on runway 22. The aircraft lifted off and climbed to approximately 200 to 300 feet. The aircraft appeared to have stalled during the ascent, banked to the right, crashing onto runway 12L/30R. It then tumbled for approximately 500 feet, coming to rest on taxiway Hotel and Mike."

"As the aircraft came more into my field of vision, it was 100 to 150 feet off the runway. I observed it roll hard to the right, become inverted, and crash into the ground. A large fireball followed the impact."

"I remember seeing the belly of the airplane, it was lime green color, then it winged-over to its right and went down."

Personnel information

The 55-year old pilot held a commercial pilot certificate with a rating for multiengine land and instrument airplane. In addition, he was also typed-rated in the Cessna 500 and 650 models. On February 20, 2005, the pilot satisfactorily completed the annual single-pilot training program and the single-pilot proficiency check in the CE-S550 airplane, as required by FAA exemption 405 and amended on June 27, 1984. The training included authorization for circling approaches.

The pilot was issued a second-class medical certificate on February 4, 2005, with the limitation that "airman must wear corrective lenses." Pilot flight records were not found; however, at the time of the medical application, the pilot reported having accumulated a total of 4,100-flight hours, with 110 hours in the last 6 months. The pilot also owned and operated a 1991-model Cessna 650 twin-engine business jet that was certified for two-pilot operation. Witnesses stated that the pilot had never flown this airplane as pilot-in-command, only as a co-pilot. From January 2005 until the accident, the pilot had flown the Cessna 650 as a co-pilot for approximately 60 hours, and had accumulated 25 hours in the last 90 days, with October 15, 2005, being his last logged flight.

It was reported to the FAA that the passenger was employed by the pilot as a maintenance technician, and had been performing maintenance on the airplane. Records reveal that the 37-year passenger was issued an airframe/powerplant mechanic certification on June 8, 1999. Previously, he had been issued a student pilots certificate (FF242243) on May 31, 2002, that expired on May 31, 2004. A first-class medical certificate was issued on May 3, 2002, with the restriction of "must wear corrective lenses." No additional records were located.

Aircraft information

The 1972-model airplane, serial number 004, was a twin-engine business turbojet, configured for a maximum of eight occupants, with a retractable landing gear. The airplane was certified for two-pilot operation, but this particular model could have been flown with only one pilot if an exempted FAA endorsement was approved. This exemption requires an FAA approved single-pilot training program, which is not controlled or approved by Cessna Aircraft Company. The airplane was powered by two 1971 Pratt & Whitney JT-15D1A engines, S/N 76177 and S/N 76633. According to Cessna owner/operator records, the initial delivery date was April 14, 1972. FAA records indicated that the airplane had been operated by 11 different owners since the airplane came off the assembly plant in 1972.

After the accident, incomplete airplane and engine records were located at different locations, and it was not determined if other records were aboard the airplane before being consumed by fire. However, the available information is as follows:

The last recorded inspections accomplished on the airplane were: phase 1 and phase 2 on August 15, 2002; phase 3 and phase 4 on June 5, 2002; and phase 5 on March 30, 2003. Phase 1-4 inspections have 2-year or 400-hour requirements. Phase 5 is a 3-year or 1,200-hour requirement.

The aircraft flight log records indicate January 31, 2005, as its last previous flight. Total aircraft time indicated 6,229.9 hours and 6,195 landings. At that time, engine 1 indicated 2,506.1 hours and 2,246 cycles, and engine 2 indicated 2,473.2 hours and 2,353 cycles.

Records that were found indicated that the accident flight was the first flight since the latest phase 1-5 inspections had been initiated; however, no completed documentation was found indicating that the inspections had been accomplished, or that the airplane maintenance was approved for the return-to-service flight.

Airframe inspection phases 1 through 5 from the maintenance manual were initialed by various mechanics, but no complete signoffs, completion dates, or component times were noted. Inspection phases 41 and 50 was signed on February 25, 2005, with total time of 6,229.9 hours and 6,195 landings.

53 pages of discrepancy worksheets (4 discrepancies to the page) were listed for the airframe, and some of the worksheets indicated corrective actions were taken, including replacing parts/components. The dates from the worksheets start on February 25, 2005, and extend to October 27, 2005. Some of the written discrepancies include: "corrosion on left and right gear axles, removed all flight controls per phase 5 inspection, right hand aft wing fairing cracked with loose rivets, repair wing fuel leaks as required, removed landing gear for repairs, replaced left and right speedbrake hydraulic lines, left and right upper outboard trailing edge of horizontal stabilizer suspected of corrosion between skin and hinge, and main entry door linkage work (reference item 155, which states that the crew door locking linkage has play)."

11 pages of discrepancy worksheets (4 discrepancies to the page) were listed for the phase 4 and 8 engine inspections. Some of the worksheets indicated corrective actions were taken, including replacing parts/components. The dates from the worksheets start on January 19, 2005, and extend to May 30, 2005. Some of the written discrepancies include: "remove left and right hand engine inlets for repair, removed right and left thrust reverser for inspection, left engine start sequence inoperative, replace all engine cowl fasteners, right pylon aft lower section has rivets pulled through, engine sync system inoperative, right and left engine fire loops improperly routed, left pylon aft trailing edge needs repair, left engine has wrong class exhaust nozzle."

On February 18, 2004, an emergency locator transmitter and antenna were installed on N505K, which changed the weight and balance status. The revision change showed the new empty weight to be 7,264.39 pounds, with the new center of gravity being 261.

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.

Loss of control - in flightTakeoff - initial climb
Door,passenger - not securedFactor
Diverted attentionPilot in commandFactor
Directional control - not maintainedPilot in commandCause
Stall/mush - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Aircraft

Registration
N505K
Reported as
Cessna 500
Category
Airplane
Serial number
500-0004
Airframe hours
6,229.9
Engines
Pratt & Whitney Canada JT15D-1A, 2,200 lbs thrust, turbo jetPratt & Whitney Canada JT15D-1A, 2,200 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 1, 2003 · 220.9 hours before
Departed
HOU · Houston, TX
Destination
CRP · Corpus Christi, TX
Flight plan
IFR
Airport
HOU · William P. Hobby, runway 22, 7,602 × 150 ft, concrete

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
55
Injuries
Fatal
Certificates
Commercial, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
February 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
4,100 total

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 10 knots
Visibility
10 statute miles
Lowest ceiling
3,000 ft broken
Temperature
81 °F, dew point 70 °F
Altimeter
29.93 inHg
Observed at
Hou

FAA reports on this event · 1

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