Aircraft Incidents and Accidents

Saturday, June 5, 1999 2:30 PM EDT
YANKEETOWN, FLORIDA 34498

NTSB Probable Cause Narrative

The failure of maintenance personnel to balance check the ruddervators after painting the airplane and unclear information contained in the compliance section of AD 94-20-04 resulting in the failure of maintenance personnel to balance check the out-of-balance ruddervators and subsequent in-flight flutter and structural damage. Findings in the investigation were 1) improper modification/repair to both propeller blades by unknown person(s) resulting in them being below specification for chord width, and one of the propeller blades being below specification for chord thickness, 2) wrong sized rivets near the trim tab of the right elevator were noted and the skin of both ruddervators was not trimmed correctly, 3) paint drips flowing towards the trailing edge of both ruddervators contrary to shop manual.

NTSB Narrative Summary Released at Completion of Accident

While in smooth air in a right descending turn in VMC conditions between 160-170 mph IAS, the pilot encountered what he thought was turbulence. He slowed the airplane and landed uneventfully at an alternate airport. Damage to the empennage was noted. Both elevators/rudders (ruddervators) were out of balance limits and discrepancies pertaining to both ruddervators were noted. The ruddervators were reskinned and rebalanced in October 1982 and the airplane was painted August 1986; no record of balance check was noted after painting (contrary to the shop manual) through the last entry in the maintenance records. Airworthiness Directive (AD) 94-20-04, effective November 28, 1994, requiring in part balance check of the ruddervators, and a stipulation to repeat the balance check if the ruddervators(s) are repaired or painted. The compliance section of the AD states, '...unless already accomplished'. The AD was completed first in October 1995, in July 1997, and last July 1998; no evidence of balance check was annotated in the maintenance records during accomplishment with the AD. The airplane had accumulated at the time of the accident approximately 79 hours since last compliance with AD 94-20-04 and approximately 156 hours since painting. The mechanic who first performed AD 94-20-04 in October 1995 stated that the ruddervators were not balance checked then due to the wording of the compliance section that states not required if previously accomplished. The mechanic also stated that AD 94-20-04 is 'hard to interpret.' Personnel from the FAA ACO stated that because the AD is subject to interpretation in the field, it may be revised. Review and analysis of the manufacturers flight test report pertaining to flutter indicated no critical frequency around 38.3 Hertz, which is the frequency when the propeller is operating at 2,300 rpm. Postaccident, the maximum vibration recorded from the engine/propeller was .6 ips; the propeller had been balanced to .15 IPS, 15 months before the accident. The maximum limit pertaining to attempting to balance the propeller established by the test equipment manufacturer is 1.2 IPS. The properly installed propeller was out of specification for chord width on both blades and for thickness for Blade No. 2. The aircraft's airspeed indicator was indicating 3-5 mph higher than the test unit when tested between 160 and 170 mph.

Event Information
Type of Event	Accident
Event Date	6/5/1999
Event Day of the Week	Saturday
Time of Event	1430
Event Time Zone	Eastern Daylight Time
Event City	YANKEETOWN
Event State	FLORIDA
Event Country	--
Zipcode of the event site	34498
Event Date Year	1999
Event Date Month	6
MidAir Collision Indicator	No
On Ground Collision occurred ?	No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport	Off Airport/Airstrip
Distance from airport in statute miles	--
Degrees magnetic from airport	--
Airport Elevation	--
Weather Briefing Completeness	Unknown
Investigator's weather source	Weather Observation Facility
Time of the weather observation	1455 Eastern Daylight Time
Direction of event from weather observation facility (degrees)	0
Weather Observation Facility ID	OCF
Elevation of weather observation facility	113
Distance of event from weather observation facility (units?)	0
Time Zone of the weather observation	EDT
Lighting Conditions	Day
Lowest Ceiling Height	0
Lowest Non-Ceiling Height	0
Sky/Lowest/Cloud Conditions	Clear
Sky Condition for Lowest Ceiling	None
Visibility Runway Visual Range (Feet)	0
Visibility Runway Visual Value (Statute Miles)	0
Visibility (Statute Miles)	10
Air Temperature at event time (in degrees celsius)	33
Dew Point at event time (in degress fahrenheit)	19
Wind Direction (degrees magnetic)	90
Variable Wind Indicator	Unknown
Wind Speed (knots)	4
Wind Velocity Indicator	Unknown
Wind Gust Indicator	Not Gusting
Wind Gust (knots)	0
Altimeter Setting at event time (in. Hg)	30
Density Altitude (feet)	--
Intensity of Precipitation	Unknown
METAR weather report	--
Event Highest Injury	None
On Ground, Fatal Injuries	0
On Ground, Minor Injuries	0
On Ground, Serious Injuries	0
Injury Total Fatal	--
Injury Total Minor	--
Injury Total None	1
Injury Total Serious	--
Injury Total All	--
Investigating Agency	NTSB
NTSB Docket Number (internal use)	1746
NTSB Notification Source	--
NTSB Notification Date	Jun 16 1999 12:00AM
NTSB Notification Time	953
Fiche Number and/or location -used to find docket information	IMAGE
Date of most recent change to record	Aug 13 2001 11:09AM
User who most recently changed record	MONR
Basic weather conditions	Visual Meteorological Cond
FAA District Office	--

Aircraft Involved
	Aircraft #1
Aircraft Registration Number	N3508B
NTSB Number	MIA99LA185
Missing Aircraft Indicator	N
Federal Aviation Reg. Part	Part 91: General Aviation
Type of Flight Plan filed	None
Flight plan Was Activated?	--
Damage	Substantial
Aircraft Fire	None
Aircraft Explosion	None
Aircraft Manufacturer's Full Name	Beech
Aircraft Model	E-35
Aircraft Series Identifier	E-35
Aircraft Serial Number	D-3725
Certified Max Gross Weight	2725
Aircraft Category	Airplane
Aircraft Registration Class	U.S. Registered/U.S. Soil
Aircraft is a homebuilt?	No
Flight Crew Seats	--
Cabin Crew Seats	--
Passenger Seats	--
Total number of seats on the aircraft	4
Number of Engines	1
Fixed gear or retractable gear	Retractable
Aircraft, Type of Last Inspection	Annual
Date of Last Inspection	Jul 6 1998 12:00AM
Airframe hours since last inspection	79
Airframe Hours	8012
ELT Installed	Yes
ELT Activated	No
ELT Aided Location of Event Site	Unknown
ELT Type	--
Aircraft Owner Name	JOHN H. DORE III
Aircraft Owner Street Address	753 CREPE MYRTLE CIRCLE
Aircraft Owner City	APOPKA
Aircraft Owner State	FL
Aircraft Owner Country
Aircraft Owner Zipcode	32712
Operator is an individual?	--
Operator Name	ROCKY L. CARMEAN
Operator Same as Owner?	No
Operator Is Doing Business As	--
Operator Address Same as Owner?	No
Operator Street Address	P.O. BOX 123
Operator City	GOTHA
Operator State	FL
Operator Country
Operator Zip code	34734
Operator Code
Owner has at least one certificate	None
Other Operator of large aircraft?	No
Certified for Part 133 or 137 Operation	Unknown
Operator Certificate Number	--
Indicates whether an air carrier operation was scheduled or not	--
Indicates Domestic or International Flight	--
Operator carrying Pax/Cargo/Mail	--
Type of Flying (Per_Bus / Primary)	Personal
Second Pilot on Board	No
Departure Point Same as Event	No
Departure Airport Code	ORL
Departure City	ORLANDO
Departure State	FL
Departure Country
Departure Time	1330
Departure Time Zone	EDT
Destination Same as Local Flt	--
Destination Airport Code	CDK
Destination City	CEDAR KEY
Destination State	FL
Destination Country
Specific Phase of Flight	Other
Report sent to ICAO?	--
Evacuation occurred	--
Date of most recent change to record	Jan 14 2001 10:25AM
User who most recently changed record	dbo
Since inspection or accident	--
Event Location Runway Number and Location	0
Runway Length	--
Runway Width	--
Sight Seeing flight	No
Air Medical Flight	No
Medical Flight	--