Accident Details
Probable Cause and Findings
the noninstrument-rated pilot's intentional operation of the airplane with known deficiencies in equipment (inoperative attitude indicator and directional gyro) with an estimated time of arrival after official twilight. Also, poor in-flight planning decision by the pilot for continuing the flight after encountering dark night conditions resulting in spatial disorientation and a loss of control. Contributing to the accident were: the insufficient standards/requirements of the operator for allowing the airplane to be flown by a noninstrument-rated pilot with inoperative attitude instruments with an estimated time of arrival after official twilight, the dark night and an inoperative attitude indicator.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On December 6, 1996, about 1825 central standard time, a Beech D-45, N99065, registered to the Navy Memphis Flying Club, experienced an in-flight break-up and crashed near Poplarville, Mississippi. Visual meteorological conditions prevailed in the area at the time and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the private-rated pilot and passenger were fatally injured. The flight originated about 1615 from the Memphis Naval Air Station (NAS) Millington, Tennessee.
According to documents filed by the pilot before departure with the Navy Memphis Flying Club, the planned flying cruise altitude of the flight was 3,500 feet.
Witnesses near the crash site observed the airplane flying westbound oscillating both vertically and laterally. The airplane was then observed rotating about the longitudinal axis then several reported that the airplane pitched nose down. One of the witnesses reported that while descending, the engine rpm was heard to increase and another reported hearing an explosion. The sound of impact was then heard. The witnesses reported that it was a dark night in the area at the time of the accident and there was no adverse weather in the vicinity. Three of the witnesses reported seeing either a flashing red light, or white lights on the airplane illuminated just before the accident.
PERSONNEL INFORMATION
Information pertaining to the pilot is contained on page 2 of the NTSB Factual Report-Aviation. Review of his airman's file revealed he was not instrument rated. Before departure, he indicated on the flight clearance form that he checked the aircraft discrepancy log. Review of his pilot logbook revealed that he had flown this airplane on two flights in the month before the accident for a total of 4.7 hours night. The pilot remarked in his logbook for one of the flights "...suction pump inop...," and on the other flight he remarked "low clouds, suction pump inop, radio hard to read dial..." He also recorded in his logbook .5 hour actual instrument time and 8.1 hours simulated instrument time.
AIRCRAFT INFORMATION
The airplane was modified in 1990 to operate the front and rear seats attitude indicator and directional gyro instruments by an engine mounted vacuum pump. The vacuum pump was recorded in the discrepancy log as being inoperative on September 23, 1996, and was not cleared when the flight departed. The flying club mechanic stated that the day before the accident he removed the vacuum pump and placed a plate over the vacuum pump mount pad due to a leaking garlock seal. He then plugged the lines to the vacuum pump filter and to the instruments and he stated that the instrument panel was already placarded to indicate that the vacuum system was inoperative. He further stated that new seals which had been ordered arrived the day before the accident in the afternoon but he did not install the new seal and vacuum pump. The airplane was not equipped with a standby attitude indicator but was equipped with electrically operated turn coordinators located in both instrument panels. The airplane was also equipped with one NAV/Com transceiver and a portable GPS.
A discrepancy written by the accident pilot pertaining to the comm display side of the com/nav transceiver was repaired about 2 weeks before the accident by an FAA certified repair station and the unit was reinstalled in the airplane. The discrepancy log sheet was not signed off as being corrected due to additional avionics work to the DME that was pending. Review of the airplane flight manual revealed that the maximum design maneuvering speed is 148 knots and to "use controls with caution above 150 knots."
METEOROLOGICAL INFORMATION
Information pertaining to the weather is contained on page 4 of the NTSB Factual Report-Aviation. The pilot reported on the flying club flight clearance form that he received a weather briefing at 2120. According to flight service station personnel in the Jackson, Tennessee, Flight Service Station, the pilot did not obtain a weather briefing either with the FAA or through the Direct User Access Terminal (DUAT's) or file a flight plan with the FAA for the accident flight. The base meteorology office was closed about 1 year earlier and the pilot did not have by either name or pilot certificate number access to either of the two DUAT vendors. Additionally, the flying club did not have access by name with either of the DUAT vendors. The flying club rules require filing and activation of a flight plan on each and every cross country flight, as well as obtaining a weather briefing for the proposed flight.
Review of the area forecast for the southern half of Mississippi for the estimated time of arrival which was about 1833 revealed that the ceiling was forecast to be 3,000 feet broken with tops to 5,000 feet. The outlook was for marginal VFR due to a ceiling caused by mist and haze. Review of the Aerodrome Forecast for an airport located about 20 nautical miles east-northeast of the destination airport revealed that at the estimated time of arrival, a 1,500 foot scattered layer and 3,000 feet broken ceiling were forecast to exist. A weather observation taken at the Gulfport-Biloxi Regional Airport (GPT) at 1847 hours (about 22 minutes after the accident) indicates in part a 2,500 foot broken ceiling existed. The GPT airport was located about 29 nautical miles from the accident site.
Sun and Moon calculations revealed that on the day, time, and location of the accident, the end of nautical twilight occurred at 1753 hours. The illumination of the moon was calculated to be 19 percent and according to witnesses near the accident site, it was a dark night. The crash site was located in an area with minimal ground reference lights.
COMMUNICATIONS
The pilot was not in contact with any Air Traffic Control Facility. Review of non-discrete radar data from the Houston Air Route Traffic Control Center (ARTCC) revealed that a target was observed in an area north of the crash site. Beginning at 1810.27, and squawking 1200, the target was observed flying in a southeasterly direction at 3,300 feet mean sea level. The radar data continued with a turn to the east then the south with the flight path paralleling a major highway. The radar target continued flying in a southerly direction flying over the Poplarville-Pearle River County Airport and continued at 3,500 feet until 1822. 52 when the radar data indicated that the flight was at 3,400 feet. The target remained at that altitude for the next 5 radar returns each 12 seconds apart until 1824.04, when the target was observed at 3,300 feet and remained there for the next 3 radar hits. The following target at 1824.52 indicated that the flight was at 3,200 feet and remained there for 1 additional target until 1825.16, which the radar data indicates that the airplane was at 3,600 feet, a climb of 400 feet in 12 seconds. The next radar target 12 seconds later indicates that the airplane descended 1,500 feet. That was the last radar target for the non-discrete transponder code which was located about .19 nautical mile and 160 degrees magnetic from the crash site. The radar data also indicates that the heading change from the third to the second to last radar return was from 177 to 197 degrees. The ground speed average for each of the last two, 1-minute segments of recorded radar data was calculated to be 135 and 128 knots respectively.
WRECKAGE AND IMPACT
Examination of the accident site revealed that the airplane crashed in a level sparsely populated area with few ground reference lights. The main wreckage consisted of the fuselage with a 1-foot section of the left wing attached. The right wing, both horizontal stabilizers with elevators and the vertical stabilizer and rudder assemblies were separated. Damage to two 80-foot tall trees were noted.
The first major component of the wreckage path was the vertical stabilizer/rudder which exhibited evidence of being displaced to the left. Crushing on the leading edge was noted. Following in order were the left horizontal stabilizer/elevator, the outer section of the right wing, the left aileron trim tab, the rudder counterweight, and the right wing flap section. The component locations were observed along a line on a magnetic heading of about 304 degrees. Continuing about 231 feet from the right wing flap section on a magnetic heading of 345 degrees was impact about 52 feet above ground level with trees with the left wing. The wreckage was located in a crater about 4 feet deep, 49 feet from the impact point with the trees which correlates to a descent angle of 042 degrees. Components found in the immediate vicinity of the wreckage crater include the left and right elevator counterweights, sections of the right elevator, the inboard section of the right wing, a section of the left wing, and the left horizontal stabilizer. The right main landing gear was found forward of the wreckage crater.
Examination of the vertical stabilizer/rudder assembly revealed it was failed to the left. The left horizontal was observed to be failed down and the upper skin surface exhibited signatures consistent with the impact from the leading edge of the vertical stabilizer/rudder assembly. The right wing was failed positive in two locations, near the wing root and about 6 feet outboard of the wing root. Examination of all the fracture surfaces revealed evidence of overload failure. An impact signature of the right aileron with the adjacent wing section indicates that the aileron was in a down position at impact. Additionally, scratches on the upper surface of the right wing were observed and measured which revealed they were similar in width to the canopy support structure. All flight control counterweights and components necessary to sustain flight were located in the ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# MIA97FA034