NTSB Factual Report

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 immediate vicinity of the crash site. The left wing which was found in three pieces was examined and found to be impacted by a tree about midspan of the aileron. The landing gear and flaps were determined to be retracted at the point of impact. The engine was separated from the airframe and was found in the main wreckage crater which consisted of the fuselage. The propeller hub was still attached to the engine but both propeller blades were separated from the hub and were found in the wreckage crater. Examination of one of the blades revealed curling of the blade tip and leading edge twisting towards low pitch. Tree trunk cut by propeller contact was noted. The left wing navigation light bulb filament was examined and found to be stretched. The engine was recovered for further examination.

Examination of the engine revealed that the accessory case was broken from the engine as well as the accessories. A mount plate was observed in place of the mount location of the engine driven vacuum pump. Impact damage to both crankcase halves was noted forward of both forward cylinders. Crushing was noted to the top portions of the cylinders and continuity of the crankshaft and camshaft was noted though both were noted to be impact damaged. Examination of the oil pump and oil scavenge pump revealed no evidence of preimpact failure or malfunction. The carburetor, magnetos, and propeller were not disassembled. Examination of the main bearings of the engine revealed no evidence of lack of lubrication or heat distress. Examination of the engine and components revealed no evidence of preimpact failure or malfunction.

MEDICAL AND PATHOLOGICAL

Postmortem examinations of the pilot and passenger were performed by Stephen T. Hayne, M.D., F.C.A.P., Designated Pathologist Mississippi State Medical Examiner. The cause of death for both was listed as airplane crash. Disease was not noted for both. Toxicological testing of specimens of the pilot was performed by the FAA Toxicology and Accident Research Laboratory. The unsuitable condition of the specimen resulted in positive findings for ethanol, and aceltaldehyde. No other drugs were detected.

TESTS AND RESEARCH

Postcrash examination of the electrically operated turn coordinators from the front and rear seat instrument panels revealed in part circumferential scoring of the rotor of the pilot's and rear seats turn coordinators. The front seat turn coordinator was found to be jammed with dirt related to the impact. The rear seat turn coordinator was not jammed with dirt.

Visual examination of the rear seat generator failure bulb filament using a 15 power stereo bench microscope revealed the filament was stretched.

Examination of the generator revealed that the drive shaft was impact damaged and not failed; the splines were in good condition. The generator drive gear assembly in the accessory section was not failed and rotated freely. Impact damage was noted to the coils on the armature which precluded testing. Examination of the commutator revealed no evidence of arching or overheating. Visual examination of two of the four carbon brushes revealed the outer edge of the rivet that secures the two wires to the brush was within or less than 1/16th inch from it to the brush frame adjacent to the commutator. Examination of the field windings revealed impact damage which precluded testing but there was no evidence of overheating. The airplane was equipped with a 24-volt storage battery and as previously mentioned, witnesses reported seeing airplane lights illuminated and the transponder was operating just before impact.

ADDITIONAL DATA/INFORMATION

Review of the airplane request for cross-country flight form submitted by the pilot revealed the estimated time of departure was 1400 hours. Reportedly after the pilot arrived at the flying club to depart, corrective action pertaining to the landing gear was not signed as being completed though the discrepancy had been reportedly repaired. The accident pilot flew the airplane around the traffic pattern then after landing, fueled the airplane. The flight plan paperwork left with the flying club does not indicate the intended destination of the accident flight. The end of nautical twilight at the destination airport was calculated to be 1754 hours. The calculated time of arrival at the destination airport based on the actual time of departure was 1833 hours.

The flight clearance authority (FCA) approving individual for the accident flight was the club manager who was not a licensed pilot and had no formal training relating to dispatching airplanes. The national Navy flying club regulations allowed her to grant FCA without being a licensed pilot. By Navy nationwide flying club regulations, the individual granting FCA is required to verify that the aircraft is equipped with required instruments.

The local Flying Club regulations allowed a pilot who was not instrument rated to fly a club airplane on a night cross country VFR flight with certain flight time requirements and a check out with the Chief Flight Instructor. The pilot was signed off by the president of the flying club on November 11, 1996, for night cross-country flights. The National Navy flying club regulations required that flying club airplanes shall not be flown on a night cross-country flight unless it is in part equipped for instrument flight as required by 14 CFR Part 91.205.

Review of 14 CFR Part 91.205 revealed in part that two of the required instruments are a gyroscopic pitch and bank indicator (artificial horizon) and a gyroscopic direction indicator (directional gyro or equivalent). Review of 14 CFR Part 91.213 revealed in part that no person may take off an aircraft with inoperative instruments or equipment installed unless an approved minimum equipment list (MEL) exists for that aircraft. The airplane did not have an approved MEL. Additionally, the regulation states what instruments and equipment may not be included in a MEL; which are in part, instruments and equipment that are either specifically or otherwise required by the airworthiness requirements under which the aircraft is type certificated and which are essential for safe operations under all operating conditions.

NTSB Probable Cause

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.