Aviation Accident Summaries

Aviation Accident Summary FTW91LA110

ADDISON, TX, USA

Aircraft #1

N18989

Beech B19

Analysis

THE STUDENT PILOT'S DOOR OPENED IMMEDIATELY AFTER TAKEOFF. THE TAKEOFF WAS CONTINUED WITH REPEATED ATTEMPTS MADE TO CLOSE THE DOOR. THE AIR TRAFFIC CONTROL TOWER WAS ADVISED OF THE SITUATION BUT AN EMERGENCY WAS NOT DECLARED. WHILE ON AN EXTENDED FINAL APPROACH, WHICH RESULTED FROM ATCT INSTRUCTIONS, CONTROL OF THE AIRPLANE WAS LOST DUE TO THE OPEN DOOR. THE AIRPLANE COLLIDED WITH TREES AND CAME TO REST IN A RESIDENTIAL AREA. THE INSTRUCTOR HAD NEVER DEMONSTRATED A DOOR OPEN SITUATION IN FLIGHT. BEECHCRAFT HAD ISSUED SPECIFIC PROCEDURES FOR THIS EMERGENCY IN MARCH, 1987, VIA A SAFETY COMMUNIQUE. THESE PROCEDURES WERE NEVER INCORPORATED INTO THE PILOT'S OPERATING HANDBOOK. THE FAA OPERATIONS INSPECTOR, THE OPERATOR, THE FLIGHT INSTRUCTOR AND THE STUDENT PILOT HAD NO KNOWLEDGE OF THE SAFETY COMMUNIQUE PROCEDURES.

Probable Cause and Findings

ENTRY DOOR OPENING IN FLIGHT, INADEQUATE EMERGENCY PROCEDURES PUBLISHED BY THE MANUFACTURER, AND POOR EMERGENCY TRAINING BY THE STUDENT'S INSTRUCTOR. FACTORS WERE INADEQUATE DESIGN/INSTALLATION OF THE DOOR LOCKING MECHANISM, DETERIORATED AIRPLANE PERFORMANCE, AND THE PILOT'S FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE.

 

Source: NTSB Aviation Accident Database

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