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NTSB investigation record

CEN12FA421

Completed

Beech E90· N987GM

Date
July 7, 2012
Location
Karnack, TX
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's inadvertent flight into thunderstorm activity, which resulted in the loss of airplane control and the subsequent exceedance of the airplane's design limits and in-flight breakup. Contributing to the accident was the failure of air traffic control personnel to use available radar information to provide the pilot with a timely warning that he was about to encounter extreme precipitation and weather along his route of flight or to provide alternative routing to the pilot.

Investigator assessment

Analysis narrative

Before the flight, the pilot did not obtain a weather briefing and departed without approval from company personnel. The airplane departed the airport about 0230 and climbed to 14,500 feet mean sea level. The pilot obtained visual flight rules (VFR) flight following services from air traffic control (ATC) personnel during the flight. While the airplane was en route, ATC personnel advised the pilot that an area of moderate precipitation was located about 15 miles ahead along the airplane's flight path. The pilot acknowledged the transmission and was then directed to contact another controller. About 3 minutes later, the new controller advised the pilot of an area of moderate to extreme precipitation about 2 miles ahead of the airplane. The pilot responded that he could see the weather and asked the controller for a recommendation for a reroute. The controller indicated he didn't have a recommendation, but finished by saying a turn to the west (a right turn) away from the weather would probably be better. The pilot responded that he would make a right turn. There was no further radio contact with the pilot. Flight track data indicated the airplane was in a right turn when radar contact was lost. A review of the radar data, available weather information, and airplane wreckage indicated the airplane flew through a heavy to extreme weather radar echo containing a thunderstorm and subsequently broke up in flight. Postaccident examination revealed no mechanical malfunctions or anomalies with the airframe and engines that would have precluded normal operation. During the VFR flight, the pilot was responsible for remaining in VFR conditions and staying clear of clouds. However, Federal Aviation Administration directives instruct ATC personnel to issue pertinent weather information to pilots, provide guidance to pilots to avoid weather (when requested), and plan ahead and be prepared to suggest alternate routes or altitudes when there are areas of significant weather. The weather advisories and warnings issued to the pilot by ATC were not in compliance with these directives. The delay in providing information to the pilot about the heavy and extreme weather made avoiding the thunderstorm more difficult and contributed to the accident.

Source record

Factual narrative

HISTORY OF FLIGHT On July 7, 2012, at 0404 central daylight time, a Beech E90, N987GM, operated by Win Win Aviation, Inc., De Kalb, Illinois, was destroyed when it impacted terrain near Karnack, Texas. The commercial pilot was fatally injured. No flight plan had been filed for the 14 Code of Federal Regulations Part 91 positioning flight. The flight departed from the De Kalb Taylor Municipal Airport (DKB), DeKalb, Illinois, approximately 0230, and was en route to Brownsville, Texas. According to the owner of Win Win Aviation, the airplane was recently purchased from an air medical company and underwent maintenance and refurbishment for sky diving operations. The pilot was a contract pilot for Win Win Aviation and was hired to fly the airplane to Mexico to deliver aircraft parts, and ultimately deliver the airplane to a sky diving company. The pilot arrived at the operator's facility at DeKalb approximately 1430 on July 6th, and inquired about the status of the airplane. The owner of Win Win Aviation instructed the pilot to await the return the chief mechanic prior to the intended flight, in order for the chief mechanic to inspect a recent propeller installation and return the airplane to service. The chief mechanic was out of town and expected to return later in the evening. The pilot then returned to a hotel approximately 1600. The chief mechanic returned to the facility approximately 0010 on July 7th. The mechanic called the owner and reported he was too tired to complete the required inspection. Prior to leaving the facility, the chief mechanic saw the pilot and instructed him to return in the morning. The chief mechanic left the facility and had no further communication with the pilot. The pilot departed from DKB approximately 0230. At 0336:45, the pilot contacted the Dallas Fort Worth Air Route Traffic Control Center (ZFW ARTCC) Sector 27 after being switch by the previous ZFW sector and reported level at 14,500 feet mean sea level (msl). The ZFW Sector 27 controller acknowledged the pilot and issued the Texarkana altimeter setting of 29.97 inches of mercury. At 0359:12, the ZFW Sector 27 controller advised the pilot of an area of moderate precipitation at a distance of 15 miles and at his 12 o'clock position. The pilot acknowledged the transmission. At 0359:28, the ZFW Sector 27 controller switched the airplane to ZFW Sector 52. At 0359:57, the pilot checked in with the ZFW Sector 52 controller and reported his altitude was 14,500 feet msl. The controller responded with an altimeter setting of 29.99. At 0401:11, a United Airlines Flight 335, an Airbus Industries A320 flying from Los Angeles, California, to Orlando, Florida, checked in on the ZFW Sector 52 frequency and reported his altitude of flight level 350 (35,000 feet msl). At 0402:37, the United pilot requested a left deviation for weather and the deviation was approved by the ZFW Sector 52 controller. At 0402:55 the ZFW Sector 52 controller transmitted to the accident airplane pilot, "N7GM, I'm showing some moderate, heavy and extreme precipitation now 12 o'clock and about two miles, it just popped up and became extreme there, it's gonna extend to the south about another one five miles". The pilot responded, "Ah, yeah I'm seeing some weather, sir do you have a recommendation deviation left or right degrees?" The Sector 52 controller responded, "N7GM, no I really don't, it looks like you are heading right for it, it looks like the heavier stuff most of it is to your left, to the east so maybe going west would be better". At 0403:27, the pilot responded, "Alright sir, I'll make a 25 right". At 0403:55 the pilot of N987GM transmitted "Fort Worth Center, I'm gonna keep it going right here". The ZFW Sector 52 controller acknowledged the transmission and at 0404:01 transmitted "That's fine N7GM, whichever way you need to go is fine". At 0405:08 the ZFW Sector 52 controller asked the pilot if he was through the weather, and there was no response. Starting at 0405:37, the ZFW Sector 52 controller made three unsuccessful attempts to contact the pilot with the last transmission at 0407:15. Witnesses who were residents in the vicinity of the accident site reported that a severe thunderstorm passed through that area about the time of the accident. They reported that the thunderstorm contained lightning, thunder, and heavy rain. PERSONNEL INFORMATION The pilot, who was seated in the left front seat position, held a commercial pilot certificate with airplane multi-engine land and airplane single-engine land ratings. The commercial certificate contained the following limitation, "Not valid for carriage of persons for hire in airplanes on cross-country flights of more than 50 nautical miles or at night." The pilot was issued a second-class medical certificate on June 14, 2012, with a restriction for corrective lenses for distant and near vision. According to the Federal Aviation Administration's (FAA) airman records, the pilot reported on his most recent medical application he had accumulated 5,300 total flight hours. According to records obtained from the operator, the pilot's most recent flight review was satisfactorily conducted on July 6, 2011. The records, which were excerpts of the pilot's logbook, indicated that as of July 6, 2011, the pilot had accumulated 9,103.6 total flight hours and 6,525.4 hours in multi-engine airplanes. The logbook also indicated the pilot had accumulated 718 actual instrument flight hours. The pilot did not hold an airplane instrument rating. The operator reported that the pilot was an experienced, good pilot, and most often flew for sky diving companies. The operator also stated the pilot did not typically fly with a handheld global position system (GPS), and probably was not familiar with the operation of the installed weather avionics on the airplane. The accident flight was the first flight for the pilot in the accident airplane. AIRCRAFT INFORMATION The accident airplane, a Beech E90 (King Air), serial number LW-65, was a high performance, low wing, semi-monocoque design airplane. The airplane was powered by two 680-horsepower Pratt & Whitney PT6A-28 engines (serial numbers PCE-41799 and PCE-50620). The airplane was equipped with 4-bladed, Hartzell HC-B4TN-3A propellers. Flight controls were installed for the left seat only. The airplane's maximum takeoff weight was 10,100 pounds (lbs) and useful load was 3,681 lbs. The airplane was issued a standard airworthiness certificate on August 20, 1973, and was maintained under a continuous airworthiness inspection program. According to the maintenance records obtained from the owner, the airplane underwent Phase 1 through Phase 4 inspections and additional miscellaneous maintenance that was completed on June 30, 2012. At the time of the maintenance, the airframe had a total time of 15,081.2 hours. The left engine (serial number PCE-41799) had accumulated 31,056 hours and 45,534 cycles since new; 5,524 hours since overhaul, and 1,214 hours since hot section overhaul. The right engine (serial number PCE-50620) had accumulated 7,859 hours and 8,373 cycles since new; and 3,619 hours and 2,630 cycles since overhaul. The airplane was equipped with a Bendix/King RDS-82 weather radar system and IN-182A radar indicator. The system was capable of providinig continuous en route weather information relative to cloud formations, rainfall rate, thunderstorms, and storm detection up to a distance of 240 miles. The indicator contained front panel selections of power, range, tilt adjustment of antenna, receiver gain control, hold, self-test, and stab adjustment. The airplane was also equipped with a BFGoodrich Avionics Systems WX-900 Weather Mapping System stormscope. METEOROLOGICAL INFORMATION Harrison County Airport (ASL), 3 miles southeast of Marshall, Texas, had an Automated Weather Observing System (AWOS) whose reports were not supplemented by a human observe

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