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Cases › DFW08FA056 · Part 135 fatal

AERO COMMANDER 500BCentral Air Southwest

Tulsa, OK, USA · 2008-01-17·N712AT

1
fatal
0
serious
Fatal
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

The commercial pilot departed on a night instrument flight rules flight in actual instrument meteorological in-flight conditions. Less than 2 minutes after the airplane departed the airport, the controller observed the airplane in a right turn and instructed the pilot to report his altitude. The pilot responded he thought he was at 3,500 feet and he thought he had lost the gyros. The pilot said he was trying to level out, and when the controller informed the pilot he observed the airplane on radar making a 360-degree right turn , the pilot said "roger." Three minutes and 23 seconds after departure the pilot said "yeah, I'm having some trouble right now" and there were no further radio communications from the flight. The on scene investigation disclosed that both wings and the tail section had separated from the airframe. All fractures of the wing and wing skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. The deformation of the wings indicated an upward failure due to positive loading. No anomalies were noted with the gyro instruments, engine assembly or accessories

Photographs

8the aircraft, and what the investigators found
Wreckage and site documentation · 8 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The pilot's loss of control due to spatial disorientation and the pilot exceeding the design/stress limits of the aircraft. Factors contributing to the accident were the pilot's reported gyro problem, the dark night conditions , and prevailing instrument meteorological conditions.

Occurrence sequence

4 stepsNTSB coding · CICTT taxonomy
  1. 1 · Initial climb
    Flight instrument malf/fail
  2. 2 · Initial climb
    Loss of control in flight
    defining event
  3. 3 · Initial climb
    Attempted remediation/recovery
  4. 4 · Initial climb
    Aircraft structural failure

Findings

6 causal · 0 contributing
  • CAUSE
    Aircraft › Aircraft systems › Vacuum system › Vacuum indicating system — Malfunction
  • CAUSE
    Personnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation — Pilot
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › Performance/control parameters — Not attained/maintained
  • CAUSE
    Aircraft › Aircraft structures › (general) — Capability exceeded
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Light condition › Dark — Not specified
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima — Not specified

NTSB analysis

from the final report

The commercial pilot departed on a night instrument flight rules flight in actual instrument meteorological in-flight conditions. Less than 2 minutes after the airplane departed the airport, the controller observed the airplane in a right turn and instructed the pilot to report his altitude. The pilot responded he thought he was at 3,500 feet and he thought he had lost the gyros. The pilot said he was trying to level out, and when the controller informed the pilot he observed the airplane on radar making a 360-degree right turn , the pilot said "roger." Three minutes and 23 seconds after departure the pilot said "yeah, I'm having some trouble right now" and there were no further radio communications from the flight. The on scene investigation disclosed that both wings and the tail section had separated from the airframe. All fractures of the wing and wing skin were typical of ductile overload with no evidence of preexisting failures such as fatigue or stress-corrosion. The deformation of the wings indicated an upward failure due to positive loading. No anomalies were noted with the gyro instruments, engine assembly or accessories