FTW04FA025

NTSB accident investigation · Beech A45 · Montgomery, TX · November 19, 2003

Accident · FatalField investigationFinal report
Date
November 19, 2003, 10:16 local (16:16 UTC)
Place
Montgomery, TX
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N44KKBeech A45
Weather
Visual (VMC) · Day
Status
Completed · report March 30, 2005
Report
Approved by Office Director
Parties
Flight Standards District Office, T-34 Association, Raytheon Aircraft Company
FAA report
20031119031159A
Case key
58362

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 non-compliance with applicable Airworthiness Directives which required wing spar inspections, and the continued operation of the aircraft beyond the compliance time extension granted as per the approved alternate means of compliance (AMOC). Also causal was the operation of the aircraft outside of its flight "G" load limitations. Contributing factors were the misunderstanding between the Federal Aviation Administration (FAA) ACO and maintenance personnel in regard to AD/AMOC compliance, the insufficient AMOC’s, and failure of the operator to adequately comply with CFR Part 91 subpart E, maintenance.

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/malfunctionManeuvering
Wing,spar - failure,totalCause
Maintenance,compliance with ad - not complied withCompany/operator managementCause
Wing,spar - fatigueCause
Improper use of equipment/aircraftCompany/operator managementCause
Insufficient standards/requirementsFaa(organization)Factor
Procedures/directives - not understoodOther maintenance personnelFactor
Information insufficientFaa(other/organization)Factor
Loss of control - in flightManeuvering
Aircraft control - not possiblePilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

While maneuvering in a simulated air-to-air combat scenario with another airplane, the accident airplane was in a climbing right turn when the right wing separated from the airframe. Subsequently, the airplane spun uncontrolled to the ground. The right wing was located approximately 1/2 mile north of the main wreckage. Examination of the separated wing revealed extensive fatigue cracking in both forward and aft wing spars. On July 9,1999, AD 99-12-02 was issued by the FAA mandating flight and operating limitations on all Beech A45 (T-34) aircraft until structural inspection procedures could be developed. The AD prohibited operations in acrobatic and utility categories, limited the flight load from to 2.5 "G's" and limited the maximum airspeed to 175 mph. Entries in maintenance logbooks indicated that AD 99-12-02 was accomplished on June 3,1999. A former customer of the operator had flown in the accident airplane in May, 2001, and recalled that during the flight, the instructor pilot told him that they pulled about positive 6 "G's." On August 16, 2001, the FAA issued AD 2001-13-18, which superseded AD 99-12-02, and required inspections of the wing spars for cracks per Raytheon Aircraft Company (RAC) mandatory Service Bulletin (SB) 57-3329. AD 2001-13-18 allowed the operator an alternative method of compliance (AMOC) or an adjustment to the compliance time if the method provides an "equivalent level of safety" to the AD. On November 13, 2001, the airplane underwent a 100-hour inspection at which time log entries indicated that paragraphs d(1), d(2), and d(3) of AD 2001-13-18 were complied with and that paragraphs d(5), d(6), and d(7) were complied with by August 2002. On August 26, 2002, at an aircraft total time of 8,031.4 hours, compliance with the remaining provisions of AD 2001-13-18, through the use of an AMOC, began with inspections of the rear spar bathtub fittings per the T-34 Technical Committee Report. No discrepancies were noted at this time. On December 16, 2002, the FAA issued a revised Special Airworthiness Information Bulletin (SAIB) number CE-02-38R2 to advise all operators to the available AMOCs for compliance with AD 2001-13-18. The aircraft then underwent two subsequent 100-hour inspections and an annual inspection with no work noted related to the AMOC. On November 5, 2003, the aircraft underwent a 100-hour inspection and entries in the logbook indicated that the mechanic called the FAA Aircraft Certification Office (ACO) in Wichita, Kansas, and inquired about a possible time extension to comply with AD and AMOC requirements. According to the logbook entry, the representative from the ACO informed the mechanic that "as long as the rear spar inspection was complied with that the aircraft could continue to fly but the limiations specified in AD 99-12-02 would remain until AMOC completed." In a written statement, the representative from the ACO stated that he received a telephone call concerning the T-34 wing AD and SAIB, regarding certain AMOC's. He reported that the operator informed him "that the aircraft was coming up on the two hundred hour limit specified in the SAIB and that the aircraft would be grounded because the replacement spar was not yet installed. The operator wanted to know what could be done to continue flying." The ACO representative further stated that he informed the operator to "perform the inspections required by the AD. This would permit the aircraft to continue flying until the mod could be completed." On November 5, 2003, the rear bathtub fitting inspection was again performed with no discrepancies noted, 220.5 hours since the first bathtub fitting inspection. No documentation of a scheduled AMOC modification was found in the aircraft logbook. According to available records, the aircraft had not completed any AMOC or the Raytheon Service Bulletin. The lower wing bathtub fitting had been inspected allowing operation beyond the 80-hour limit with restrictions, about 2 weeks prior to the accident. On March 15, 2004, the FAA published AD2001-13-18 R1, which rescinded all previously approved AMOC's for the T-34 wing. The new AD also grounded any T-34 that had not accomplished the Raytheon Service Bulletin, and had flown more than 80 hours since August 16, 2001. The FAA determined that the AMOC's listed in AD 2001-13-18 did not address all critical areas in the wing spar assembly, and should no longer be valid.

Factual narrative

History of flight

On November 19, 2003, at 1016 central standard time, a Beech A45 single-engine airplane, N44KK, registered to PRVNY PLUK, LLC, of Houston, Texas, and operated by Texas Air Aces of Spring, Texas, was destroyed when it impacted terrain following a loss of control after an in-flight breakup while maneuvering near Montgomery, Texas. The commercial pilot and pilot-rated passenger were fatally injured. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 training flight. The local flight originated from the David Wayne Hooks Memorial Airport (DWH), near Spring, Texas, approximately 0930, in the flight lead position of a flight of two airplanes.

The pilot-rated passenger attended Texas Air Aces for a two-day advanced maneuvering program (AMP), which included ground school and in-flight training that focused on unusual attitude recognition and "upset" recovery. On the morning of the accident, a pre-flight briefing was conducted by the pilot in command of the accident airplane. According to the pilot-rated passenger of the second airplane in the formation (N141SW): "The briefing included the pertinent radio and formation information for a flight of two, to and from the practice area. Loss of radio was covered. We discussed completing the AMP training from the day before. The pre-flight brief did not include air combat maneuvers, as I remember it."

According to a statement provided by the pilot of N141SW, the flight of two airplanes flew to a practice area located near Lake Conroe, approximately 15 miles north northwest of DWH. The formation flight split up upon arriving at the practice area and conducted individual upset maneuver training. After the training was completed, approximately 1010, the pilot in command of N141SW suggested to the flight leader (pilot of N44KK) that they engage in a simulated air combat demonstration. The flight leader agreed, and both airplanes rendezvoused over Lake Conroe for a "standard engagement." The pilot-in-command of N141SW stated they initially "engaged" at 7,500 feet and 140 knots. Each aircraft made a left climbing turn to begin the maneuvering. Several turns were made as the airspeed continually decreased. After two or three turns, the flight lead aircraft (N44KK) was below and to the right (4-5 o'clock position) of the second aircraft (N141SW) when it "broke up in flight and spun to the ground."

The pilot in command of N141SW squawked transponder code "seventy seven hundred" (7700) and made a "Mayday" call on VHF frequency 121.50. N141SW continued to fly over the accident site for approximately 10-15 minutes before returning to DWH. The wreckage of N44KK came to rest in a heavily wooded area, and flames were observed by the pilots of N141SW.

A witness, located .52 nautical miles south southeast of the impact point, was outside in her yard and observed the airplanes flying overhead for approximately 45 minutes. She reported that she heard two "popping noises, then a clack," like armor hitting each other, then another "pop." The engine went silent, and in the distance she heard a "pop," then a sound like a "dud fire cracker." The witness heard a whirling sound, looked up and saw a wing floating down at an approximate a 65-degree angle. She stated that she did not see the wing come off of the airplane, but observed smoke and ash flying in the air. The right wing came to rest approximately 235 feet from where the witness was located.

Several other witnesses on the ground observed both airplanes maneuvering overhead. One witness stated that both airplanes were in a "bank maneuver," when one of the airplane's "wings came off and began to spiral down." Another witness reported that they heard the engine "revving real high, full throttle," and stated that there was no collision between the two airplanes.

Personnel information

The pilot-in-command, who occupied the rear seat, was a co-founder of Texas Air Aces and had been an employee since 1992. He held a commercial pilot certificate with airplane single-engine land, airplane multi-engine land, and instrument airplane ratings. He also held a flight instructors certificate. The pilot was issued his most recent Federal Aviation Administration (FAA) second-class medical certificate on November 11, 2003, with a limitation requiring the holder to wear corrective lenses. At the time of the pilot's most recent medical certificate application, he reported a total of 15,100 flight hours. The pilot's logbooks were not recovered.

The pilot-rated passenger, who occupied the front seat, held an airline transport certificate with type ratings in the DC-9 and DO-328, a commercial pilot certificate with an airplane single-engine land rating, and a flight engineer certificate. He also held a flight instructors certificate. He was issued his most recent FAA first-class medical certificate on October 6, 2003, with a limitation requiring the holder to wear corrective lenses. At the time of his last medical application, he reported a total of 5,650 flight hours.

Aircraft information

The 1965-model Beech A45 single-engine airplane, serial number G-714 was a low wing, semi-monocoque design airframe, configured for a maximum of two occupants in a tandem seating configuration. Originally, the primary function of the aircraft was a primary military trainer. Many of these military trainers, when de-commissioned by the military, were bought, refurbished, and utilized in the civil aviation community. According to the airplane operating handbook, the airplane (when manufactured) was capable of gravity (g) loading limits from +6g to -3g. The airplane was powered by a Continental IO-520-BB engine, rated at 285-horsepower, driving a three bladed constant speed Hartzell propeller.

On July 9, 1999, Airworthiness Directive (AD) 99-12-02 was issued by the FAA. The AD mandated flight and operating limitations on all Beech A45 aircraft until structural inspection procedures could be developed. The AD limited the aircraft to normal category operations and prohibited operations in acrobatic and utility categories. Additionally, the AD limited the flight load factor from "0" to "2.5" G's and limited the maximum airspeed to 175 miles per hour (mph).

On August 16, 2001, the FAA issued AD 2001-13-18, which superseded AD 99-12-02, and was applicable to all Beech A45 aircraft. AD 2001-13-18 maintained the actions required in AD 99-12-02 (paragraphs d(1), d(2), d(3), and d(4)) until such time as the inspection required in paragraph d(5) is accomplished as summarized below.

d(1) Install placards on the airplane instrument panels (both front and back) next to the airspeed indicators in the pilot's clear view: "Never exceed speed, VNE 175 mph (152 knots) IAS; Normal Acceleration (G) Limits 0, and +2.5; ACROBATIC MANEUVERS PROHIBITED." Insert this AD into the aircraft flight manual (AFM). Required prior to further flight after July 9, 1999.

d(2) Mark the airspeed indicator with a red radial line at 175 mph and a white slippage index mark. Required within 10 hours time in service (TIS) after July 9, 1999.

d(3) Mark the "g" meters with red lines at 0 and +2.5 and a white slippage index mark. Required within 10 hours TIS after July 9, 1999.

d(4) The actions indicated in d(1-3) above are no longer required after the initial inspection in d(5)

d(5) Inspect the wing spars for cracks per Raytheon Aircraft Company (RAC) mandatory Service Bulletin (SB) 57-3329. Required within the next 80 hours TIS after August 16, 2001, or within 12 months after August 16, 2001, whichever is later. Inspect thereafter at intervals not to exceed 80 hours TIS.

d(6) Replace any cracked wing spar found in d(5) prior to further flight. A crack indication in the filler strip is allowed if the crack direction is toward the outside edge of the part.

Aircraft

Registration
N44KK
Reported as
Beech A45
Category
Airplane
Serial number
G-714
Airframe hours
8,257.4
Engine
Continental IO-520-BB, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Operator
Texas Air Aces
Registered owner
Prvny Pluk, LLC
Airworthiness certificate
Standard, Aerobatic
Last inspection
100 hour · November 5, 2003 · 5.5 hours before
Departed
DWH · Spring, TX
Airport
CXO · Montgomery County 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
64
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Rear
Toxicology
Performed
Flight hours
15,100 total
Role
Pilot
Age
39
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight engineer, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Front
Toxicology
Performed
Flight hours
5,650 total

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 37 °F
Altimeter
30.26 inHg
Observed at
CXO, 17 nm away

FAA reports on this event · 1

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