DFW08FA056

NTSB accident investigation · Aero Commander 500B · Tulsa, OK · January 17, 2008

Accident · FatalField investigationFinal report
Date
January 16, 2008, 22:43 local (Jan 17, 2008, 04:43 UTC)
Place
Tulsa, OK
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N712ATAero Commander 500B
Defining event
Initial climb: Loss of control in flight
Weather
Instrument (IMC) · Night
Status
Completed · report June 11, 2009
Report
Approved by Office Director
Parties
Air Central Southwest, Parker Parker Hannifin, transportation Safety Institute, Lycoming Textron, Twin Commander, Federal Aviation Administration, FSDO, Hartzell Propellers and Governors
FAA report
20080116010449A
Case key
67386

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 pilot's loss of control due to spatial disorientation and the pilot exceeding the design/stress limits of the aircraft. Factors contributing to the accident were the pilot's reported gyro problem, the dark night conditions , and prevailing instrument meteorological conditions.

Findings · 6

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.

Vacuum system: vacuum indicating systemAircraft › Aircraft systems · MalfunctionAero Commander 500-B: 1 caseAll aircraft: 1 caseProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedAero Commander 500-B: 2 casesAll aircraft: 1,269 casesProbable cause
AircraftAircraft › Aircraft structures · Capability exceededAero Commander 500-B: 1 caseAll aircraft: 72 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Not specifiedAero Commander 500-B: 1 caseAll aircraft: 448 casesProbable cause
Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Not specifiedAero Commander 500-B: 1 caseAll aircraft: 184 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 commercial pilot departed on a night instrument flight rules flight in actual instrument meteorological in-flight conditions. Less than 2 minutes after the airplane departed the airport, the controller observed the airplane in a right turn and instructed the pilot to report his altitude. The pilot responded he thought he was at 3,500 feet and he thought he had lost the gyros. The pilot said he was trying to level out, and when the controller informed the pilot he observed the airplane on radar making a 360-degree right turn , the pilot said "roger." Three minutes and 23 seconds after departure the pilot said "yeah, I'm having some trouble right now" and there were no further radio communications from the flight. The on scene investigation disclosed that both wings and the tail section had separated from the airframe. All fractures of the wing and wing skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. The deformation of the wings indicated an upward failure due to positive loading. No anomalies were noted with the gyro instruments, engine assembly or accessories

Factual narrative

History of flight

On January 16, 2008, at 2043 central standard time, a twin-engine Aero Commander 500-B airplane, registered as N712AT, was destroyed during an in-flight break-up and subsequent impact with terrain following a loss of control after take-off from Runway 36L at the Tulsa International Airport, near Tulsa, Oklahoma. The commercial pilot, sole occupant of the airplane, was fatally injured. The airplane was registered to and operated by Central Air Southwest, Inc., of Kansas City, Missouri, and was being utilized as an on demand air-carrier flight, hauling canceled bank checks. Dark night instrument meteorological conditions prevailed in the area at the time for the cargo flight conducted under 14 Code of Federal Regulations Part 135. An instrument flight rules flight plan had been filed and activated for the 94-nautical mile night cross-country flight from the Tulsa International Airport (TUL) to the Wiley Post Airport (PWA), near Oklahoma City, Oklahoma.

Authorities at the airport reported that soon after departing TUL, the pilot reported that he was having gyro problems. The airplane was observed on radar and was given instructions to turn left to 300 degrees. The pilot initiated a right turn and was informed by Tulsa approach control that "you are turning right, turn left to 300 degrees." The aircraft continued a steep right turn for two complete 360 degree turns and disappeared from the radar scope. The wreckage of the airplane was located about 90 minutes after the accident in a remote wooded area of Mohawk Park, approximately 1 3/4 miles north of the airport. There was no fire.

Injuries to persons

The pilot was fatally injured. There were no injuries to anyone on the ground.

Damage to aircraft

The wreckage of the twin-engine airplane was located about 90 minutes after the accident in a remote wooded area of Mohawk Park, approximately 1.75 miles north of the airport (010 degrees from the departure end of the runway). There was no post-impact fire.

Personnel information

The 31-year old instrument rated pilot held a commercial certificate for single and multi-engine land airplanes. His last first class medical certificate was issued on November 19, 2007. The operator reported that the pilot had accumulated a total of 4,373-flight hours, of which 695-hours were in the same make and model aircraft. Additionally, the pilot was reported to have accumulated 255-hours in the preceding 90-days, with l83 in the last 30 days. The pilot's last biennial flight review was completed on November 29, 2007, in an Aero Commander 500-B.

The operator reported that the pilot was very familiar with the airplane and he had completed the scheduled flight almost on a daily basis since he joined the company.

Aircraft information

The 1961-model Aero Commander 500-B, serial number 1118-68, was reported to have accumulated a total of 17,888-flight hours at the time of its last inspection on January 10, 2008. The airplane has a maximum takeoff weight of 6,750-pounds, and the weight of the airplane at the time of takeoff from Tulsa was estimated at 6,005-pounds.

The aircraft was powered by two-290-horsepower IO-540-B1A5 Lycoming engines. The number one engine (left), serial number L-154-48, had accumulated a total of 126-hours since its last overhaul. The number two engine (right), serial number RL-7521-48, had accumulated a total of 1,276-hours since its last overhaul.

Meteorological information

The weather at the TUL airport at the time of the accident was reported as, a broken ceiling at 600 feet, an overcast ceiling at 1,900 feet, visibility 3 miles in rain and snow, temperature 31 degrees Fahrenheit, with winds from 300 degrees at 18 knots, gusting to 24 knots. The pilot was reported to have received a weather briefing for the flight.

Communications

The Tulsa Air Route Traffic Control Center (ARTCC) personnel reported that at 45 seconds into the flight the pilot of N712AT, was cleared to climb to 6,000-feet and was given a left turn to a heading of 250-degrees, and cleared direct to PWA. The accident pilot acknowledged this transmission. At 1 minute and 59 seconds into the flight the controller noted that N712AT was in a right turn. At 2 minutes and 55 seconds the controller requested N712AT to report the altitude he was leaving and the pilot responded "3,500 I think I have lost my gyros, I'm trying to level out now". The controller responded "roger, you just made a right 360," to which the pilot responded "roger." At 3 minutes and 23 seconds after departure, the controller transmitted "712AT, you still appear to be in a right turn," to which the pilot responded "yeah, I'm having some trouble right now." At 3 minutes and 54 seconds the controller transmitted "712AT, I'm not getting a target on you, say altitude now." No response was received from the accident aircraft, and the accident airplane had disappeared from the radar scope. No further transmissions were received by the Tulsa ARTCC personnel.

Wreckage and impact information

Examination of the aircraft wreckage was conducted at the accident site on January 18, 2008. The fractures were photographed and visually examined with a 10x magnifier and a high intensity light.

The first piece of aircraft wreckage along the debris field was the outboard portion of the left wing. The left wing was perched at a 45 degrees angle between two trees preventing extensive examination at its final resting place of North 36 degrees 13 minutes 7.51 seconds, West 95 degrees 53 minutes 4.46 seconds per the Tulsa Fire Department (TFD). All fractures of the wing structure (spars, longerons, and ribs) and wing skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. Overall deformation of the wing indicated failure upward due to positive loading.

The second piece of the aircraft wreckage found was the outboard portion of the right wing. The right wing was resting in a pile of broken tree limbs preventing extensive examination at its final resting place of North 36 degrees 13 minutes 8.54 seconds, West 95 degrees 53 minutes 5.54 seconds per the TFD. All fractures of the wing structure (spars, longerons, and ribs) and skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. Overall deformation of the wing indicated failure upward due to positive loading.

The empennage was found at North 36 degrees 13 minutes 8.64 seconds, West 95 degrees 53 minutes 5.74 seconds. The empennage was resting upright on its tail cone and its left and right horizontal stabilizer tips. The empennage separated from the aircraft at the fuselage-empennage junction just forward of the vertical stabilizer. All fractures of the fuselage-empennage structure (stringers) and skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. Overall deformation of the fuselage-empennage junction indicated failure to the starboard side. The leading edges of the vertical stabilizer and the left horizontal stabilizer contained mechanical damage due to impact with the outboard portion of the right wing (detailed later). The bottom surface of the left horizontal stabilizer contained torsion buckles forward-aft indicating upward loading and the bottom surface of the right horizontal stabilizer contained torsion buckles aft-forward indicating downward loading. The left horizontal stabilizer upward loading and the right horizontal stabilizer downward loading indicates rolling of the aircraft from left to right which is characteristic of an in-flight breakup due to the right wing failing first.

The rudder was found approximately 20 yards north of the empennage. The rudder was fractured and folded in half. All the fractures of the rudder structure and skin were typical of ductile overload wit

Aircraft

Registration
N712AT
Reported as
Aero Commander 500B
Category
Airplane
Serial number
1118-68
Airframe hours
17,888
Engines
Lycoming IO540-E1A5, 290 horsepower, reciprocatingLycoming IO540-E1A5, 290 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Central Air Southwest, doing business as Central Air Southwest, Inc.
Registered owner
Central Air Southwest
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
AAIP · January 10, 2008
Departed
KTUL · Tulsa, OK
Destination
KPWA · Oklahoma City, OK
Flight plan
IFR
Airport
KTUL · Tulsa International Airport

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
31
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 29, 2007
Seat
Left
Toxicology
Performed
Flight hours
4,373 total · 695 in this make and model · 255 in the last 90 days · 83 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
300° at 18 knots, gusting 21
Visibility
3 statute miles
Lowest ceiling
800 ft overcast
Temperature
32 °F, dew point 34 °F
Altimeter
30.00 inHg
Observed at
KTUL, 1 nm away

Docket · 20

The files NTSB released with the investigation on April 3, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.5 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.