ERA10IA095

NTSB incident investigation · Beech 58 · Lexington, KY · December 10, 2009

Incident · No injuriesIncident investigationFinal report
Date
December 10, 2009, 12:05 local (17:05 UTC)
Place
Lexington, KY
Injuries
2 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N391MCBeech 58
Defining event
Approach-VFR go-around: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Hawker Beechcraft Coorporation, FAA/FSDO
FAA report
20091210052329I
Case key
75156

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 overstress failure of the nose landing gear aft drag brace.

Findings · 1

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.

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 pilots were practicing instrument approaches and performed a missed approach. At that time, the landing gear was retracted and the corresponding gear retracted cockpit indication was noted; however, the approach controller advised the pilots that the nose landing gear appeared to remain in the extended position. The pilots then selected the nose landing gear to the extended position and noted the corresponding gear extended cockpit indication. During a subsequent landing, the nose landing gear collapsed and the airplane slid to a stop on the runway. Examination of the airplane revealed that the right side of the nose landing gear aft drag brace had separated. Metallurgical examination revealed that the origin point of the fracture was consistent with overstress, and the fracture extended from the origin point over a significant period of time. The airplane had accumulated over 10,000 hours of flight time, and the initiation of the overstress event was most likely the result of a previous hard landing or landings. Review of the maintenance manual for the make and model airplane revealed that the nose gear was an "on condition" inspection item; however, the fracture was in an area that would not be easily visible or detected by a mechanic during an inspection.

Factual narrative

On December 10, 2009, about 1205 eastern standard time, a Beech 58, N391MC, operated by Air Lexington Inc., incurred minor damage while landing at Blue Grass Airport (LEX), Lexington, Kentucky. The certificated airline transport pilot and certificated commercial pilot were not injured. Visual meteorological conditions prevailed and no flight plan was filed for the local flight, which originated from LEX about 1030. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The pilots reported that the commercial pilot was practicing instrument approaches, while the airline transport pilot acted as a safety pilot. During a go-around at LEX, the commercial pilot retracted the landing gear and noted the corresponding gear retracted cockpit indication; however, the LEX Approach controller advised the pilots that the nose landing gear appeared to be in the extended position. The pilots then selected the landing gear to the extended position and noted the corresponding gear extended cockpit indication. During a subsequent landing, after touchdown on runway 22, the nose landing gear collapsed and the airplane slid to a stop on the runway. Examination of the airplane by a Federal Aviation Administration (FAA) airworthiness inspector revealed damage to the nose gear area and both propellers. The examination also revealed that the right side of the nose landing gear aft drag brace had separated. The inspector also noted that the nose landing gear indicating system and linkage remained intact and undamaged. The right side nose landing gear aft drag brace was forwarded to the NTSB Materials Laboratory, Washington, DC. The FAA inspector also forwarded photographs of the damage to a representative of the aircraft manufacturer. The representative noted that review of the photographs revealed that a plug used to contain linoil within the drag brace appeared to be missing. Additionally, the component tubing appeared to be absent of linoil, which was required per Hawker Beechcraft Specification 455. The representative added that the incident airplane was manufactured in 1976 and the manufacturer redesigned the component in 1977 to reduce man-hours required to fabricate the component. The redesigned component was forged and not constructed of tubing, which also eliminated the need for a plug and linoil. The representative further stated that review of the manufacturer’s field condition reports did not reveal any record of similar failures to the same model nose landing gear aft drag brace. Examination of the component by an NTSB metallurgist revealed that the origin point of the fracture exhibited features consistent with overstress. Additionally, the metallurgist noted “crack arrest marks” along the fracture extension, consistent with an overstress failure over a period of time. The fracture initiated from a different area than that of the missing linoil plug. The investigation could not positively determine if the plugdeparted before or after the failure of the component. Review of the maintenance manual for the make and model airplane revealed that the nose gear was an "on condition" inspection item; however, the FAA airworthiness inspector noted that the fracture was in an area that would not be easily visible or detected by a mechanic during an annual or 100-hour inspection. The incident airplane was maintained under an FAA approved inspection program (AAIP). The airplane's most recent AAIP inspection was completed on November 9, 2009. The airplane had accumulated 20.2 hours of operation since that inspection and had accumulated 10,437.3 total hours of operation at the time of the incident.

Aircraft

Registration
N391MC
Reported as
Beech 58
Category
Airplane
Serial number
TH-756
Airframe hours
10,437
Engines
Cont Motor IO 520 SERIES, 285 horsepower, reciprocatingCont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Minor damage
Flight
Personal · Part 91
Operator
Air Lexington Inc
Registered owner
Air Lexington Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 9, 2009 · 20 hours before
Departed
LEX · Lexington, KY
Destination
LEX · Lexington, KY
Airport
LEX · Blue Grass Airport, runway 22, 7,003 × 150 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
66
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 30, 2009
Seat
Right
Flight hours
20,381 total · 1,663 in this make and model · 17,043 as pilot in command · 25 in the last 90 days · 6 in the last 30 days · 0 in the last 24 hours
Role
Pilot
Age
33
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
February 9, 2009
Seat
Left
Flight hours
3,478 total · 25 in this make and model · 3,130 as pilot in command · 7 in the last 90 days · 7 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 18 knots, gusting 25
Visibility
9 statute miles
Lowest ceiling
3,400 ft broken
Temperature
23 °F, dew point 12 °F
Altimeter
30.09 inHg
Observed at
LEX

Docket · 6

The files NTSB released with the investigation on April 6, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.7 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.