FTW91FA043
1991-02-22 · TULSA, Oklahoma, United States · Fatal · 1 aircraft · Status: Completed
Airport TUL
N274MA has since been reassigned. It is now registered to a different aircraft (PIPER PA-28-181, built 2024), which was not involved in this event.
Aircraft involved
Probable cause & findings
THE SHUTDOWN OF ONE ENGINE FOR UNDETERMINED REASONS, AND THE PILOT'S FAILURE TO MAINTAIN VMCA DURING A CRITICAL PHASE OF FLIGHT. A FACTOR IN THE ACCIDENT WAS THE PILOT'S IMPROPER EMERGENCY PROCEDURE.
Factual narrative
AIRPLANE WAS DEPARTING ON A REQUIRED MAINTENANCE TEST FLIGHT FOLLOWING REPLACEMENT OF BOTH ENGINES. WITNESSES STATED THAT THE TAKEOFF ROLL AND INITIAL CLIMB APPEARED NORMAL, BUT THAT AT ABOUT 500 FT AGL, THE AIRPLANE ENTERED A RIGHT BANK WHICH CONTINUED UNTIL THE WINGS WERE VERTICAL AND THE NOSE FELL THROUGH. AIRPLANE IMPACTED IN AN INVERTED STEEP NOSE DOWN ATTITUDE. EXAMINATION OF WRECKAGE REVEALED THAT THE RIGHT ENGINE HAD BEEN SECURED AND FEATHERED. SUBSEQUENT INVESTIGATION DID NOT REVEAL ANY EVIDENCE OF PRE-IMPACT FAILURE OR MALFUNCTION OF EITHER ENGINE OR ANY OF THE AIRFRAME SYSTEMS. ENGINE MOUNTING/RIGGING CONTINUITY COULD NOT BE ESTABLISHED DUE TO IMPACT DAMAGE. THE PILOT WAS A PRINCIPAL IN THE OPERATOR'S ORGANIZATION AND NOT ONE OF THE REGULAR LINE PILOTS. EVIDENCE INDICATED THAT THE GEAR WAS UP AND THAT THE LEFT SPOILER WAS DEPLOYED AT IMPACT. EMERG PROCEDURE TAUGHT IN TRANSITION TRAINING IS TO USE RUDDER TRIM AS SOON AS POSSIBLE AFTER ENG FAILURE TO PRECLUDE DEPLOYMENT OF SPOILERS. RUDDER TRIM FOUND IN NEUTRAL POSITION. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1991_FTW91FA043.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA) From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- Semantic Scholar 2025 · Article (Applied Sciences) Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…