Pilot Debrief

BEECH E-90 near Des Moines, IA — 2011-02-15

Final reportCEN11LA192
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Date
2011-02-15
Location
Des Moines, IA, USA
Aircraft
BEECH E-90
Registration
N51DN
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Maneuvering

Probable cause

The improper installation of the right aileron by maintenance personnel.

NTSB narrative

The airplane had recently undergone maintenance, which included an inspection of the ailerons requiring removal, reinstallation, and a functional check. Prior to the test flight, the pilot performed a pre-flight inspection of the airplane and a flight control free and correct check with no anomalies noted. While executing a turn at flight level 180, the right aileron departed the airplane. The airplane landed without further incident. Examination of the airplane revealed the inboard and middle airframe aileron hinge brackets were attached to the aft spar, intact, and showed no visible damage. The outboard airframe aileron hinge bracket was pulled and separated from the aft spar. The aileron was not located. Based on the condition of the hinge brackets, the evidence indicated the aileron bolts were not properly engaged in the aileron nut plates which caused the bolts to fall out and the aileron to depart the airplane.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Properly check aileron installation after maintenance before flight.

NTSB coding

Evidence available

  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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