Aircraft Accident/Incident Report

Eagle Lake, Texas
Wednesday, September 11, 1991 10:03 CDT

NTSB Narrative Summary Released at Completion of Accident

THE AIRPLANE BROKE UP IN FLIGHT WHILE DESCENDING FROM FL240. THE HORIZONTAL STABILIZER, OR TOP OF THE T-TYPE TAIL, HAD SEPARATED FROM THE FUSELAGE BEFORE GROUND IMPACT. EXAMINATION REVEALED THAT THE 47 SCREW FASTENERS THAT WOULD HAVE ATTACHED THE UPPER SURFACE OF THE LEADING EDGE ASSEMBLY FOR THE LEFT SIDE OF THE HORIZONTAL STABILIZER WERE MISSING. THEY HAD BEEN REMOVED THE NIGHT BEFORE DURING SCHEDULED MAINTENANCE. INVESTIGATION REVEALED THAT THERE WAS A LACK OF COMPLIANCE WITH THE FAA-APPROVED GENERAL MAINTENANCE MANUAL PROCEDURES BY THE MECHANICS, INSPECTORS, AND SUPERVISORS RESPONSIBLE FOR ASSURING THE AIRWORTHINESS OF THE AIRPLANE THE NIGHT BEFORE THE ACCIDENT. IN ADDITION, ROUTINE SURVEILLANCE OF THE CONTINENTAL EXPRESS MAINTENANCE DEPARTMENT BY THE FAA WAS INADEQUATE AND DID NOT DETECT DEFICIENCIES, SUCH AS THOSE THAT LED TO THIS ACCIDENT.

NTSB Probable Cause Narrative

THE FAILURE OF CONTINENTAL EXPRESS MAINTENANCE AND INSPECTION PERSONNEL TO ADHERE TO PROPER MAINTENANCE AND QUALITY ASSURANCE PROCEDURES FOR THE AIRPLANE'S HORIZONTAL STABILIZER DEICE BOOTS THAT LED TO THE SUDDEN IN-FLIGHT LOSS OF THE PARTIALLY SECURED LEFT HORIZONTAL STABILIZER LEADING EDGE AND THE IMMEDIATE SEVERE NOSE-DOWN PITCHOVER AND BREAKUP OF THE AIRPLANE. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WAS THE FAILURE OF CONTINENTAL EXPRESS MANAGEMENT TO ENSURE COMPLIANCE WITH THE APPROVED MAINTENANCE PROCEDURES, AND THE FAILURE OF THE FAA SURVEILLANCE TO DETECT AND VERIFY COMPLIANCE WITH APPROVED PROCEDURES. (NTSB REPORT AAR-92/04)

Event Information

Type of Event Accident
Event Date 9/11/1991
Event Day of the Week Wednesday
Time of Event 1003
Event Time Zone Central Daylight Time
Event City EAGLE LAKE
Event State TEXAS
Event Country --
Zipcode of the event site
Event Date Year 1991
Event Date Month 9
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 Unknown
Time of the weather observation 950 Central Daylight Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID
Elevation of weather observation facility 0
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation CDT
Lighting Conditions Day
Lowest Ceiling Height 3000
Lowest Non-Ceiling Height 3000
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 6
Air Temperature at event time (in degrees celsius) 28
Dew Point at event time (in degress fahrenheit) 23
Wind Direction (degrees magnetic) 70
Variable Wind Indicator Unknown
Wind Speed (knots) 7
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 Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 14
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 14
Investigating Agency NTSB
NTSB Docket Number (internal use) 2312
NTSB Notification Source --
NTSB Notification Date Sep 10 1991 12:00AM
NTSB Notification Time 2300
Fiche Number and/or location -used to find docket information 44183
Date of most recent change to record Dec 12 2000 10:44AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N33701
NTSB Number DCA91MA052
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire Ground and In-flight
Aircraft Explosion None
Aircraft Manufacturer's Full Name EMBRAER
Aircraft Model 120
Aircraft Series Identifier 120
Aircraft Serial Number 120-L77
Certified Max Gross Weight 26000
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 30
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Sep 10 1991 12:00AM
Airframe hours since last inspection --
Airframe Hours 7229
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name
Aircraft Owner Street Address
Aircraft Owner City
Aircraft Owner State
Aircraft Owner Country
Aircraft Owner Zipcode
Operator is an individual? --
Operator Name CONTINENTAL EXPRESS
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address HOUSTON INTERCONTINENTAL ARPT
Operator City HOUSTON
Operator State TX
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate Yes - certificate holder
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 Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code LRD
Departure City LAREDO
Departure State TX
Departure Country
Departure Time 909
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code IAH
Destination City HOUSTON
Destination State TX
Destination Country
Specific Phase of Flight Descent
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:30AM
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 --