ERA19LA137

NTSB accident investigation · Pilatus PC12 · Fort Lauderdale, FL · March 24, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 24, 2019, 11:01 local (15:01 UTC)
Place
Fort Lauderdale, FL
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N944BTPilatus PC12
Defining event
Enroute-climb to cruise: Aircraft structural failure
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA, PPG
FAA report
20190324001959A
Case key
99173

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

Improper maintenance of the windshield, which resulted in delamination and in-flight depressurization.

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: repairPersonnel issues › Task performance · Maintenance personnelPilatus PC-12/45: 1 caseAll aircraft: 99 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

During the climb to cruise altitude on a cross-country flight, the pilot heard a loud bang and the pilot's side windshield shattered and the cabin began depressurizing. The pilot returned to the departure airport and landed uneventfully, where he noticed that the seal was extruded in two places around the outer pane. The windshield was sent to the manufacturer for a detailed examination, which revealed that 80% of the fiberglass straps were missing, and they were likely removed by maintenance personnel. A combination of missing straps and heavy delamination caused the outboard ply to become detached from the edge attachment. Moisture ingress at the bottom aft edge caused delamination and arcing. There was no record in the airframe logbook of the straps’ removal.

Factual narrative

On March 24, 2019, about 1101 eastern daylight time, a Pilatus PC-12/45, N944BT, was substantially damaged when the pilot's windshield shattered while flying near Fort Lauderdale, Florida. The commercial pilot and two passengers were not injured. Visual meteorological conditions prevailed, and an instrument flight plan was filed for the flight that originated from the Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, and was destined for Moore-Murrell Airport (MOR), Morristown, Tennessee. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, he was climbing through 20,000 ft when he heard a loud bang and the pilot-side windshield shattered. He immediately notified air traffic control that he was returning to FXE and needed to descend. After landing uneventfully, he examined the windshield and noticed that the seal was extruded in two places around the outer pane. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the pilot-side windshield was shattered but was still attached to the airplane. The bottom left corner and upper corner of the windshield were pushed outward, and the seal around the windshield was torn. The lower left heating element was burnt. The windshield was sent to the manufacturer for further examination. The examination revealed that about 80% of the fiberglass straps were missing and had been removed by maintenance personnel. The missing straps caused the outboard ply to become detached from the edge attachment. Moisture was then able to ingress the bottom aft edge causing delamination and then allowing arcing to occur. Investigators were unable to determine when these straps were removed, as there was no record of this maintenance in the airframe logbooks. The Pilatus Windows Inspection Check referred to the PPG service information letter which states specifically the straps should not be removed, rather repaired following their prescribed maintenance plan. The pilot held a commercial pilot certificate with ratings for airplane single-engine land, single-engine sea, and multi-engine land. His most recent FAA third-class medical certificate was issued on November 15, 2017. He reported 9,000 total hours of flight experience, of which 2,600 hours were in the PC-12. The airplane was manufactured in 2002. It was powered by a Pratt and Whitney PT6A-67, 1,250-horsepower engine, equipped with a four-bladed Hartzell propeller. Its most recent annual inspection was completed on January 15, 2019.

Aircraft

Registration
N944BT
Reported as
Pilatus PC12 (45)
Category
Airplane
Serial number
468
Built
2002
Airframe hours
2,558
Engine
Pratt & Whitney Canada PT6A-67B, 1,250 horsepower, turbo prop
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 15, 2019 · 10 hours before
Departed
FXE · Fort Lauderdale, FL
Destination
KMOR · Morristown, TN
Flight plan
IFR
Equipment
Onboard weather, Stall warning system, ADS-B, Angle of attack indicator, Electronic multifunction display, Electronic primary flight display

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
73
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
May 23, 2018
Seat
Left
Restraint
3-point
Flight hours
9,000 total · 2,600 in this make and model · 9,000 as pilot in command · 30 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Temperature
75 °F, dew point 61 °F
Altimeter
30.10 inHg
Observed at
FXE, 8 nm away

Docket · 8

The files NTSB released with the investigation on October 15, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.6 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.