LAX96FA106

NTSB accident investigation · Convair C-131E · Saint Johns, AZ · February 5, 1996

Accident · FatalField investigationFinal report
Date
February 5, 1996, 09:50 local (16:50 UTC)
Place
Saint Johns, AZ
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N131TConvair C-131E
Weather
Visual (VMC) · Day
Status
Completed · report October 4, 1996
Report
Approved by Office Director
FAA report
19960205003559A
Case key
29257

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

inadequate preflight planning and preparation by the first pilot (PIC), his failure to ensure the aircraft was properly loaded within limitations, his failure to use proper flaps for takeoff, his failure to use ADI assisted takeoff, and his resultant failure to attain sufficient airspeed to climb after takeoff. Factors relating to the accident were: the high density altitude, and the PIC's lack of experience in the 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.

In flight collision with objectTakeoff - initial climb
Preflight planning/preparation - inadequatePilot in commandCause
Lack of total experience in type of aircraftPilot in commandFactor
Aircraft weight and balance - exceededPilot in commandCause
Flaps - not usedPilot in commandCause
Weather condition - high density altitudeFactor
Airspeed - not attainedPilot in commandCause
Object - wall/barricade
Object - wire,transmission
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Witnesses observed the aircraft departing from runway 14 with a rolling start. They said the aircraft rotated at the departure end of the runway and remained in ground effect with an excessive, nose high attitude. It then struck the airport perimeter fence, a barrier wall, and power lines. Power line wires were dragged through a residentual area, resulting in additional damage. The airplane then crashed in a pasture and burned. Investigation revealed the airplane had been loaded to a gross weight (GW) of 50,870 lbs. Its maximum GW was limited to 48,000 lbs at sea level with the use of antidetonation injection (ADI) fluid and 40,900 lbs without ADI. Density altitude at the airport was 6200 feet. For conditions at the airport, maximum GW for takeoff with ADI and 15 degrees of flaps was 43,205 lbs; without ADI and with 13 degrees of flaps, maximum GW was 38,909 lbs. The airplane flaps were found in the retracted position, but there was no performance data for takeoff with the flaps retracted. No ADI fluid was found in the line to the right engine, although it was intact; the ADI tank was destroyed; the ADI line to the left engine was damaged. The airplane was being flown under provision of a ferry permit, which did not provide for the cargo or the two passengers that were aboard. The first pilot (PIC) had accrued about 8 hours of flight experience in the make and model of airplane.

Factual narrative

On February 5, 1996, at 0950 hours mountain standard time, a Convair C-131E, N131T, collided with wires at the departure end of runway 14 and crashed in a residential area of Saint Johns, Arizona. The airplane was destroyed by impact forces and postimpact fire. Both pilots and two passengers were fatally injured. The airplane was operated by Business Air Connection of the Netherlands Antilles as a ferry flight under 14 CFR Part 91. The flight originated in Saint Johns, and was destined for Brownsville, Texas. Visual meteorological conditions prevailed at the time and a VFR flight plan was filed.

According to witnesses, the pilot executed a rolling takeoff from the 5,323-foot-long runway. The airplane used the full length of the runway, and did not climb high enough to clear obstacles located below the obstacle free clear zone at the departure end of runway 14. The terrain off the end of the runway slopes down. Witnesses reported the airplane's altitude along the flight path appeared to contour the terrain.

The airplane first struck the top of the airport perimeter fence and a barrier wall for three 10,000 gallon diesel fuel storage tanks. The airplane continued to fly at a low altitude and struck a tree with the right propeller. The airplane then struck residential power transmission wires with the left propeller. The wires became entangled in the airplane's landing gear and were pulled off their poles and dragged through a residential neighborhood to the accident scene.

The airplane eventually struck the ground with the left wing tip and cartwheeled into a horse pasture damaging the pasture fence.

Other Damage

In addition to the damage to the fences, barrier wall, trees, and wires, there was damage to residences. One home was struck by tree branches that penetrated into the interior and another home had minor roof damage from the dragged cables.

The damage to the home that was struck by the penetrating tree branches was limited to the bathroom and living room window. The resident of the home said he was sitting in the living room at the time. He told Safety Board investigators that the tree branches had punched a hole in the bathroom sink, shattered the toilet tank, and cracked the bathtub. There was also water damage in the bathroom as a result of the toilet being shattered.

Crew Information

First Pilot

The first pilot held an airline transport pilot certificate which was issued on April 4, 1979. At the time of the accident the pilot held 18 different type ratings, none of which were for Convair aircraft.

The most recent first-class medical certificate was issued to the pilot on December 21, 1995, and contained the limitation that correcting lenses for near vision be worn while exercising the privileges of his airman certificate. The pilot also held an existing non-disqualifying waiver for defective color vision.

No personal flight records were found for the pilot and the aeronautical experience listed in this report was estimated from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. In addition, information was obtained from a review of letters of authorization held by the pilot.

On February 2, 1996, the Federal Aviation Administration's (FAA) Sacramento Flight Standards District Office (FSDO), Sacramento, California, issued the first pilot a Letter of Authorization (LOA) to act as pilot-in-command in lieu of a type rating in Convair C-131E (CV-440), N131T, on a ferry flight from Hollister, California, to Aruba, Netherlands Antilles. The LOA limited operations to day visual flight rules (VFR) with fuel or maintenance stopover points. The LOA specified, " No other person other than the pilot and necessary crew shall be carried." The authorization expired at the completion of the ferry flight, or no later than February 17, 1996.

According to the FAA, "Vintage/surplus military aircraft are those aircraft which are operated solely under Title 14 of the Code of Federal Regulations (14 CFR) part 91 and for which the FAA does not have sufficient qualified inspector staff to conduct either the initial qualifications or proficiency tests required under existing regulations." FAA Order 8700.1 states circumstances may arise that require an aircraft be flown by a pilot who does not hold a type rating for that aircraft. An operations inspector may issue an LOA provided the flight can be accomplished safely.

The order describes to FAA Aviation Safety Inspectors (Operations) the method to determine eligibility of pilot to be issued an LOA. The order indicates regulatory provisions of 14 CFR Part 61.58 (Pilot-in-command proficiency check: Operation of aircraft requiring more than one required pilot), permits a pilot to serve as pilot-in-command provided no persons or property are carried, and the flights are conducted under day VFR conditions.

The FAA operations inspector, who granted the authorization for the first pilot, indicated to the Safety Board that he already knew of the first pilot's qualifications. The operations inspector indicated the first pilot was National Designated Pilot Examiner (NDPER) active in vintage aircraft, that the first pilot held a Letter of Operational Authority for numerous makes and models of high performance piston airplanes, and that the first pilot had been issued three previous authorizations to ferry this specific type aircraft.

On August 29, 1995, the first pilot applied for a LOA to ferry the accident airplane from Tucson, Arizona, to San Luis Obispo, California. The first pilot indicated in his application that he had two previous letters authorizing him to act as pilot-in-command, and had accumulated about 200 hours in various models of twin piston engine Convair aircraft. The FAA subsequently issued the LOA for the ferry flight on August 31, 1995.

The second pilot on the ferry flight from Tucson indicated the flight was flown without incident, except the destination was changed to Hollister, California, because San Luis Obispo was not VFR due to low visibility and fog.

On September 26, 1989, the FAA issued the first pilot a LOA to ferry a Convair 240 from Oakland, California, to Eagles Nest Airport, Ione, California.

On December 27, 1977, the FAA issued the first pilot a LOA to ferry a Convair 240 from Frankfurt, West Germany, to Kingman, Arizona.

Second Pilot

The second pilot held airline transport pilot certificate which was issued on October 20, 1995, with a multiengine airplane rating and commercial privileges for single engine airplanes.

The most recent first-class medical certificate was issued to the second pilot on January 8, 1996, and contained the limitation that correcting lenses be worn while exercising the privileges of his airman certificate.

The second pilot's total aeronautical experience consists of about 1,905 flight hours, of which about 487 were accrued in multiengine airplanes. There were no records found indicating the pilot had flown large aircraft over 12,500 pounds.

Aircraft Information

The airplane, a vintage/surplus military Convair C-131E (Civil Designation Convair 440-72), military serial number 55-4751(Civil serial number 338), was manufactured on July 20, 1956, and was delivered to the United States Air Force (USAF).

The airplane had accumulated a total time in service of 18,715 hours. Examination of copies of the maintenance records filed with the FAA before the accident revealed that the most recent annual inspection was accomplished on January 25, 1996, about 4 flight hours before the accident.

A minimum flight crew of pilot and copilot is required for all operations.

Aircraft Certification and Registration

The airplane remained in the possession of the USAF until January 13, 1994, at which time the USAF Museum Program sold the airplane to the Lan-Dale Company, Reno, Nevada. The Lan-Dale Company

Aircraft

Registration
N131T
Reported as
Convair C-131E
Category
Airplane
Serial number
338(55-4751)
Airframe hours
18,715
Engine
P&W R-2800-CB16, 2,400 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Ferry · Part 91
Registered owner
Robertus S. Kelder
Airworthiness certificate
Special, Special flight (Special); Standard, Transport
Last inspection
Annual · January 25, 1996 · 4 hours before
Departed
SJN
Destination
BRO · Brownsville, TX
Flight plan
VFR
Airport
SJN · St Johns Ind Airpark, runway 14, 5,323 × 75 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
61
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
18,400 total · 8 in this make and model · 12,000 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 4 knots
Visibility
40 statute miles
Temperature
54 °F, dew point 30 °F
Altimeter
30.00 inHg
Observed at
SOW, 35 nm away

Docket · 61

The files NTSB released with the investigation on August 1, 1996, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.4 MB in all.

Supplement A - Wreckage DocumentationItem 1 · .PDF · 169 KBSupplement B - Cockpit DocumentationItem 2 · .PDF · 262 KBSupplement E - Second Pilot InformationItem 3 · .PDF · 118 KBSupplement K - Occupant, Survival and Injury InformationItem 4 · .PDF · 642 KBSupplement N - Fire/ExplosionItem 5 · .PDF · 127 KBSupplement S - Aircraft Occupant and Injured Ground PersonnelItem 6 · .PDF · 43 KBWitness StatementsItem 7 · .PDF · 665 KBWitness Statement of Larry Penner (with 6 color photos)Item 8 · .PDF · 46 KBPhoto 1.Item 9 · .PDF · 20 KBPhoto 2.Item 10 · .PDF · 28 KBPhoto 3.Item 11 · .PDF · 29 KBPhoto 4.Item 12 · .PDF · 28 KBPhoto 5.Item 13 · .PDF · 23 KBPhoto 6.Item 14 · .PDF · 24 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 15 · .PDF · 83 KBWeather Reports and RecordsItem 16 · .PDF · 93 KBFAA Inspector's StatementItem 17 · .PDF · 379 KBFAA Export Certificate of AirworthinessItem 18 · .PDF · 80 KBOperating LimitationsItem 19 · .PDF · 120 KBAircraft Bill of SaleItem 20 · .PDF · 112 KBApplication for Export Certificate of AirworthinessItem 21 · .PDF · 83 KBSpecial Airworthiness Certificate for ExportItem 22 · .PDF · 114 KBRegistration CertificateItem 23 · .PDF · 65 KBStandard Airworthiness CertificateItem 24 · .PDF · 42 KBFAA Ferry Flight Authorization LetterItem 25 · .PDF · 90 KBApplication for Certificate of RegistrationItem 26 · .PDF · 92 KBFAA Order 8700.1 (Extract) Letter of Authorization in Liew of Type RatingItem 27 · .PDF · 422 KBCarburetor DiagramsItem 28 · .PDF · 106 KBWater Regulator - Side 1Item 29 · .PDF · 51 KBWater Regulator - Side 2Item 30 · .PDF · 51 KBCarburetor Diagram - Side 1Item 31 · .PDF · 34 KBCarburetor Diagram - Side 2Item 32 · .PDF · 38 KBConvair 440 InformationItem 33 · .PDF · 191 KBFlap InformationItem 34 · .PDF · 132 KBPerformance DataItem 35 · .PDF · 132 KBFuel SlipsItem 36 · .PDF · 58 KBAirplane Logbook (Extract Copies)Item 37 · .PDF · 302 KBAirplane Weight and Balance Records Recovered from Burnt DebrisItem 38 · .PDF · 176 KBCargo InformationItem 39 · .PDF · 262 KBPerformance Information from Convair 440 ManualItem 40 · .PDF · 1.1 MBFlap Information from Convair 440 ManualItem 41 · .PDF · 288 KBSecond Pilot Logbook ExtractsItem 42 · .PDF · 233 KBToxicological ReportsItem 43 · .PDF · 187 KBPhoto 1. View of wall and fence damage looking towards the departure end of runway 14.Item 44 · .PDF · 39 KBPhoto 2. View of wreckage path looking west.Item 45 · .PDF · 37 KBPhoto 3. Left tip of aileron; note cable marks.Item 46 · .PDF · 64 KBPhoto 4. View of fuselage looking towards airport on top of hill.Item 47 · .PDF · 41 KBPhoto 5. View of right engine nacelle and wing. Note: debris on wing is remains of the cockpit.Item 48 · .PDF · 56 KBPhoto 6. Left engine.Item 49 · .PDF · 63 KBPhoto 7. Right engine.Item 50 · .PDF · 50 KBPhoto 8. Left propeller.Item 51 · .PDF · 74 KBPhoto 9. Broken left propeller blade.Item 52 · .PDF · 75 KBPhoto 10. Left main landing gear.Item 53 · .PDF · 70 KBPhoto 11. View of right wing flap panel illustrating position of flaps.Item 54 · .PDF · 74 KBPhoto 12. View of right inboard flap showing measurement.Item 55 · .PDF · 56 KBPhoto 13. View of right inboard flap track and guide roller at the top of track travel.Item 56 · .PDF · 55 KBPhoto 14. Close up of right flap measurement.Item 57 · .PDF · 44 KBPhoto 15. Instrument panel.Item 58 · .PDF · 69 KBPhoto 16. Center console and quadrant.Item 59 · .PDF · 74 KBPhoto 17. ADI lines on right wing spar. Note: ADI fluid dripping from lines.Item 60 · .PDF · 60 KB
All 61 files on NTSB’s docket

FAA reports on this event · 1

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