FTW98FA092

NTSB accident investigation · Aero Commander 500-B · Ennis, TX · January 10, 1998

Accident · FatalField investigationFinal report
Date
January 10, 1998, 14:27 local (20:27 UTC)
Place
Ennis, TX
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N556BWAero Commander 500-B
Weather
Instrument (IMC) · Day
Status
Completed · report December 31, 1998
Report
Approved by Office Director
FAA report
19980110000179A
Case key
20398

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

failure of the flight crew to maintain minimum control speed (Vmc) during go-around from a single-engine approach, which resulted in loss of control and collision with power lines and the ground. Related factors were: a ruptured diaphragm in the distributor valve (flow divider) of the right engine's fuel injector system, which resulted in loss of power in the right engine; inadequate maintenance; a failure to comply with Bendix Service Bulletin RS-76; the airplane's excessive gross weight and forward center-of-gravity (CG); and both pilots' lack of experience in this make and model of airplane.

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 engine power(total) - mech failure/malfClimb - to cruise
1 engine
Fuel system,fuel flow divider/distributor - rupturedFactor
Maintenance - inadequateOther maintenance personnelFactor
Maintenance,service bulletin/letter - not complied withOther maintenance personnelFactor
Loss of control - in flightGo-around (vfr)
Precautionary landing - initiatedFlightcrew
Go-around - attemptedFlightcrew
Aircraft weight and balance - exceededFlightcrewFactor
Airspeed(vmc) - not maintainedFlightcrewCause
Lack of total experience in type of aircraftFlightcrewFactor
In flight collision with objectDescent - uncontrolled
Object - wire,transmission
In flight collision with terrain/waterDescent - uncontrolled

Analysis

After departing on an IFR flight in VFR conditions, the flight had been cleared to climb from 3,000 to 4,000 ft, when the right engine lost power. The pilots diverted toward an uncontrolled airport, secured the right engine, & cancelled their IFR clearance. They made an approach to land on runway 15, then attempted a single engine go-around. During the go-around, the airplane yawed/rolled to the right in what the passenger believed was a Vmc roll. It then struck power lines & crashed in a right wing low attitude. Investigation revealed that both pilots held multi-engine ratings. The owner said the pilot (PIC) had flown the airplane for a short time on 12/21/98; however, no other record was found to verify that either the pilot or copilot had flight experience in this make/model of airplane. Examination of the wreckage revealed evidence that the flaps were retracted, the landing gear was in transit, the left propeller was operating with power, & the right propeller was feathered. The airplane had a history of fuel flow fluctuations in the right engine. The diaphragm (P/N 364446) in the right engine distributor valve assembly was found ruptured. It was an old style diaphragm, which was colored black. Bendix Service Bulletin RS-76, issued 11/15/80, called for replacement of the black diaphragm with a red fluorosilicone diaphragm (P/N 245088) at overhaul. The engine was overhauled in June 1992. During maintenance in December 1997, both fuel system injectors & nozzles were tested; however, the distributor valve assembles were not tested. Calculations showed the airplane was loaded 116.3 lbs over the maximum allowable gross weight & 1.3 inches forward of the allowable CG range.

Factual narrative

History of flight:

On January 10, 1998, at 1427 central standard time, an Aero Commander 500-B twin engine airplane, N556BW, owned and operated by MGS Corporation of Laredo, Texas, was destroyed following collision with terrain while executing a single engine go-around. The private pilot, who was seated in the left seat, and the instrument rated commercial pilot, who was seated in the right seat, were fatally injured. A pilot rated passenger seated in the cabin received serious injuries. An instrument flight plan was filed for the Title 14 CFR Part 91 personal cross country flight, that originated from the Lancaster Municipal Airport, Lancaster, Texas, at 1415. The flight's original destination was Laredo, Texas; however, it was diverting to Ennis, Texas, at the time of the accident.

During personal interviews, conducted by the investigator-in-charge (IIC), witnesses reported that the airplane entered a close right base to final entry for runway 15 at the Ennis Municipal Airport. One witness, residing along the final approach path, observed the airplane's wings "rocking" on the approach, and at about 100 feet from the approach end of the runway, the right wing went 45 degrees low and then vertical to the ground. Near the midpoint of the runway length this witness observed the airplane entering a climb with the gear down and the left propeller turning. Another witness, residing along the final approach path, observed the airplane flying south with the left wing low and the airplane weaving back and forth toward the left side of the runway. Subsequently, the airplane flew over the runway, turned right, and descended to the ground.

Several witnesses at the airport, observed the airplane flying to the south at "50 to 75 feet above the ground. The aircraft was in a landing configuration, landing gear down, flaps down and the nose of the aircraft was up approx[imately] 10 degrees, the right engine was feathered, the aircraft was slow on airspeed." The airspeed was estimated between "70 mph and 100 mph, the wings were basically level with maybe just a little left wing low condition. The left engine was not developing full power." The airplane was "sinking." The airplane "banks shallow into the right side and in a full stall to the right." The right wing hit the ground first and then the nose of the airplane.

The passenger reported that he was seated in the rear facing seat behind the right cockpit seat. He wore a headset that permitted him to hear the cockpit voice communications as well as radio communications. The pilot's delayed the departure from Lancaster due to the weather, and the non-flying pilot (right seat) requested a second departure time from ATC. The passenger stated that the flight departed runway 13 on an IFR clearance. The non-flying pilot handled the IFR radio communications with departure control, and the flying pilot (left seat) flew the airplane. During the climb, the airplane was above the clouds approximately 4,000 feet msl, when there was a "surging of the engine followed by a total loss of engine power on the right engine." The pilots conversed about "low fuel flow to the right engine." The non-flying pilot applied rudder pressure and assisted the flying pilot in performing the emergency checklist. The passenger stated that the airplane was not maintaining altitude and the pilots verified and feathered the right engine. Flight in VFR conditions was maintained for the visual approach to the Ennis Municipal Airport.

The passenger further stated that everything "seemed textbook perfect and neither [pilot] seemed overly concerned about anything." As the airplane entered the base to final transition, the pilots agreed that they did not want to do a go-around. The airplane was aligned with runway 15 at Ennis with the landing gear extended. At a point where it looked to the passenger that they had the runway made for the landing, the passenger turned to a rearward facing position and tightened his seatbelt.

As time passed and the passenger felt that they should have been landing, he turned around and looked forward. He reported that the airplane was over halfway down the length of the runway; however, not aligned with the runway. The airplane was about 30 degrees to the right of the runway and aligned with the hangars. The "airspeed felt quite slow and we did not appear to be more than 40 feet agl." The flying pilot said "at least I can get the gear up" and he began to raise the landing gear handle. Within a fraction of a second after the gear handle was raised, the nose of the airplane pitched up approximately 10 degrees. Before the passenger could turn back facing rearward, the "left wing started up in what I believe to be a Vmc roll." The airplane rolled to the point that the wing was perpendicular to the ground before the first of two impacts. The airplane came to rest inverted. The passenger released his seat belt and exited through the passenger door. The passenger walked toward the road where he was encountered by a fire department medic responding to the site. The passenger stated that he "heard no conversation and saw nothing to indicate why we did not land before we were out of airspeed, runway, and altitude."

The passenger further stated that the fuel flow gauge was fluctuating during the inflight "surging of the engine." Acquaintances of the pilots, at the Lancaster airport, reported that the flying pilot was going to fly the airplane to Laredo, Texas, following maintenance repair of the left wing fuel tanks and the magneto timing. Due to the instrument weather conditions in the vicinity of Lancaster, the non-instrument rated pilot asked the instrument rated pilot to go on the flight and handle the IFR communications and procedures.

Personnel information:

The flying pilot was a non-instrument rated private pilot with single and multiengine land ratings. The pilot was issued a third class medical certificate on April 2, 1997. On the medical application, the pilot's total flight time was shown as 1,550 hours with 15 hours in the previous 6 months. According to the owner of the aircraft, the private pilot flew the airplane for "maybe 10 minutes" on December 21, 1998, during a maintenance flight check. No additional information on the pilot's flight time in the make and model of aircraft could be obtained.

The non-flying pilot held a commercial pilot certificate with single and multiengine land, and instrument ratings. He held a flight instructor certificate with single engine, multiengine, and instrument ratings. The non-flying pilot satisfactorily completed an FAA FAR 135 check ride on November 4, 1997, in the Piper PA-34-200 multiengine airplane. The commercial pilot's logbook indicated a total flight time of 4,833.4 hours through December 28, 1997. The logbook indicated 24.4 hours of flight time in the Piper PA-34-200 multiengine airplane in the previous 90 days. Both pilots held a mechanic certificate with airframe and powerplant ratings with FAA Inspection Authorization.

The pilot rated passenger held a private pilot certificate with a single engine land rating. He owns a single engine airplane and flies regularly from Lancaster to Laredo. He stated that he had 35 hours of dual instruction in an Aero Commander 560-A twin engine airplane.

Aircraft information:

The aircraft (S/N 1625-215) was manufactured in 1966. The airplane was imported from Canada to the United States and issued the FAA registration number of N95BS and a standard airworthiness certificate on May 4, 1992. In 1996, the FAA registration number was changed to N556BW. On March 11, 1997, a pre-purchase inspection and engine run performed at Downtown Airpark, Inc., Oklahoma City, Oklahoma, revealed numerous discrepancies including fuel pressure fluctuations, fuel flow fluctuations, and exhaust stack cracks.

During telephone interviews, conducted b

Aircraft

Registration
N556BW
Reported as
Aero Commander 500-B
Category
Airplane
Serial number
1625-215
Airframe hours
8,081
Engine
Lycoming IO-540-E1B5, 290 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Mgs Corporation
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 8, 1997 · 24 hours before
Departed
LNC · Lancaster, TX
Destination
LRD · Laredo, TX
Flight plan
IFR
Airport
F41 · Ennis Municipal, runway 15, 3,994 × 50 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,550 total

Weather

Conditions
Instrument (IMC) · Day
Wind
360° at 8 knots
Visibility
8 statute miles
Lowest ceiling
900 ft overcast
Temperature
43 °F, dew point 39 °F
Altimeter
30.00 inHg
Observed at
RBD, 23 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.