# NTSB ATL94FA071: Beech 58TC, N200DL, Gulf Shores, AL, March 27, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 27, 1994, 13:55 local (19:55 UTC) - Place: Gulf Shores, AL - Location: 30.2772° N, 87.7024° W: Placed by OpenAirDocs: center of Gulf Shores, AL, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=30.2772&lon=-87.7024&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report February 14, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 3288 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL94FA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3288/pdf - Page: https://openairdocs.org/ntsb/ATL94FA071 ## Probable cause THE PILOT'S FAILURE TO MAINTAIN AIRCRAFT CONTROL DURING THE BASE TURN. FACTORS WERE THE PILOT'S INADEQUATE PREFLIGHT, HIGH WINDS WITH GUSTS AT THE AIRPORT, AND THE PILOT'S DIVERTED ATTENTION DUE TO THE OPEN BAGGAGE DOOR. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - base turn - door,cargo/baggage - not secured (contributing factor) - door,cargo/baggage - open (contributing factor) - aircraft preflight - inadequate, pilot in command (contributing factor) - weather condition - high wind (contributing factor) - weather condition - gusts (contributing factor) - aircraft control - not maintained, pilot in command (cause) - diverted attention, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PILOT REPORTED CHECKING THE SECURITY OF THE NOSE BAGGAGE DOOR DURING HIS INITIAL PREFLIGHT, BUT SUSPECTS THAT HIS WIFE MAY HAVE OPENED THE DOOR WHILE HE WAS PARKING HIS CAR. DURING TAKEOFF ON RWY 17, AT 50 TO 100 FT AGL, THE NOSE DOOR CAME OPEN. HE STATED THAT THE LEFT WING TRIED TO DROP, AND HE CORRECTED WITH OPPOSITE AILERON AND RUDDER IN AN ATTEMPT TO CLOSE THE DOOR. HE LEFT THE GEAR EXTENDED. HE ATTEMPTED TO LAND ON RUNWAY 27. HE ESTIMATED THE SURFACE WINDS TO BE OUT OF THE SOUTH AT 25 TO 35 KTS, WITH GUSTS. HE REPORTED THAT HE LOST SPEED IN THE BASE TURN, AND THE AIRCRAFT IMPACTED THE GROUND IN A LEFT WING LOW, NOSE LOW ATTITUDE. THE AIRCRAFT CAME TO REST IN AN UPRIGHT ATTITUDE AND BURNED. AN INSPECTION OF THE NOSE DOOR REVEALED THAT THE TWO LATCHES WERE OPEN, AS WAS THE KEY LOCK. A WITNESS REPORTED THAT THE AIRCRAFT REACHED A STEEP BANK ANGLE PRIOR TO IMPACT. THE MANUFACTURER PERFORMED FLIGHT TESTS ON A SIMILAR AIRCRAFT WITH THE NOSE DOOR OPEN, AND FOUND NO AIRCRAFT CONTROL DEGRADATION. ## Factual narrative HISTORY OF FLIGHT On March 27, 1994, at 1355 central standard time, a Beech 58TC, N200DL, collided with terrain during the base turn at the Jack Edwards Airport, at Gulf Shores, Alabama. The aircraft was destroyed by impact forces and fire. The commercial pilot was seriously injured. His wife, who was a passenger, was fatally injured. The aircraft was operated under 14 CFR Part 91 by the pilot. Visual meteorological conditions existed at the time, and no flight plan was filed for the personal flight to Meridian, Mississippi. The flight was originating at the time of the accident. A witness, who was in the airport parking lot (adjacent to Runway 17), observed the aircraft take off on runway 17. He saw a dark object, which he thought was a rag, come from the nose of the aircraft. He then saw the object hesitate over the aircraft nose, then it went up and over the fuselage. He reported that the aircraft entered a gradual left hand turn, then the aircraft bank steepened to about 90 degrees as the turn progressed. He estimated that the aircraft did not climb higher than 200 feet above the ground at any time. The aircraft bank angle was very steep, with the nose about 10 degrees low, prior to impact. He did hear the engines, and did not detect any change in engine sound while the aircraft was in flight. When queried about the weather conditions at the time of the accident, he stated that it was windy at the time, with the wind direction out of the south, down the runway. The pilot was interviewed on December 14, 1994. He reported the following: He checked the security of the nose baggage door during his initial preflight inspection, but suspects that his wife may have opened the door while he was parking his car. He did not recheck the security of the nose baggage door after he returned from the parking lot. Otherwise, his preflight of the aircraft was "usual and standard." Ground operations were normal. On takeoff, at about 50 to 100 feet above ground level (agl), the nose baggage door opened up. He recalled that there was a lot of surface wind at the time, about 25 to 35 knots, with gusts, and out of the south. When the nose baggage door opened up, he corrected with right aileron, and rudder to crab the airplane into an attitude that would close the door. The door momentarily closed, and then opened again. He left the landing gear extended, hoping this would improve stability. At about 200 feet agl, and at about 105 knots, he entered a downwind for runway 27. He then turned base leg for runway 27. He recalls last seeing about 105 to 110 knots on the airspeed indicator, but during the base turn, he "lost speed." He could see the runway, but was at a steep descent angle. The next thing he knew, the ground was coming up quickly, and the aircraft impacted the ground in a left wing low, nose low attitude. He stated that the aircraft was "unflyable" with the nose door open. He stated that he fought to keep the door closed at all times while airborne, using aileron and rudder controls. He stated that the nose baggage door had never come open on any previous flight. He reported no problems with engine performance during the accident flight. PERSONNEL INFORMATION Information on the pilot is included in this report at the section titled "First Pilot Information." The pilot reported that he flew approximately 10 hours during the 90 days prior to the accident, including 4 hours in the 24 hour period prior to the accident. AIRCRAFT INFORMATION This aircraft was not equipped with a secondary latch on the hinged nose baggage door. In April, 1982, Beech Aircraft Company issued a Class I Service Instruction, Number 1195, Revision 1. The purpose of the service instruction was to provide a secondary latching feature for the nose baggage door. According to an aircraft logbook entry, dated March 4, 1983, Service Instruction 1195 was deferred by the customer during the annual inspection of that date. The aircraft was repaired for hail damage, in conjunction with an annual inspection, which was entered into the aircraft logbooks with a date of March 18, 1994. According to the logbook entry, the nose baggage door skin was replaced at that time. The excerpt from the logbook is included as an attachment to this report. Additional information on the aircraft is included in this report at the section titled "Aircraft Information." METEOROLOGICAL INFORMATION The Jack Edwards Airport is not equipped with a weather reporting facility. The weather for the Pensacola Naval Air Station is included in this report at the section titled "Weather Information." A witness account of the weather conditions at the accident site is included in the "History of Flight" section of this narrative. WRECKAGE AND IMPACT INFORMATION The main aircraft wreckage came to rest about 276 feet north of the runway 27 center line, and about 3,000 feet to the east of runway 17. The main wreckage was found in an upright position. The cockpit, cabin, nose, and wing sections were burned. The right wing tip was bent upward about 10 degrees, and the fuel tank was burned. The right aileron and flap were still in place on the right wing. The outer third of the left wing was found fragmented, and dispersed throughout the wreckage path. The left aileron was partially separated from the wing, and the separated section was found along the wreckage path. Both engines were still attached to the wings; the left propeller was separated from the engine, while the right propeller was attached to the right engine. The throwover control yoke was found in the left seat position. The landing gear actuator mechanism was in the "gear down" position. The flap actuator was found in the "30 degree down" position. The nose baggage compartment door was found at the right side of the nose area. The door was burned, and lying on top of burned nose area structure. The door was not attached to the door frame; the hinge area was burned and melted. Both nose baggage door latches (located forward and aft on the door) were found in the open (unlatched) position. The door key lock, located adjacent to the forward latch, was in the unlocked position. The latches were manually operated at the site, and closed flush with the door surface when pressed closed. The latches would open when the center button on each latch was pushed in. The hooking mechanisms, located on the interior side of each latch, were intact. MEDICAL AND PATHOLOGICAL INFORMATION A post-mortem examination of the passenger was performed by the Alabama Department of Forensic Sciences, Mobile, Alabama. TESTS AND RESEARCH The engines were removed from the airframe and taken to the Teledyne Continental Motors facility in Mobile, Alabama for disassembly and examination. Both engines were originally built as model TSIO-520-LB (310 horse power) and were later converted to TSIO-520-WB. The engine data plates were stamped TSIO-520- LBCWB in accordance with the applicable Teledyne Continental Motors service bulletin. For details of the examination, refer to the Teledyne Continental Motors Analytical Inspection Report, included as an attachment to this report. The propeller assemblies were shipped to the Hartzell Propeller facility in Piqua, Ohio for disassembly and examination. For details of the examination, refer to the Hartzell Propeller Teardown Report, included as an attachment to this report. The aircraft manufacturer was requested to provide flight test data addressing aircraft performance with an open nose baggage door. Beech Aircraft Corporation leased a model 58TC and conducted a series of flight tests between September 30, 1994, and October 7, 1994. The aircraft was configured so that the nose baggage door could be opened via the cockpit, with a winch and cable assembly. A series of four test flights were conducted, progressing from a flight profile with the door part ## Aircraft - Registration: [N200DL](https://openairdocs.org/deregistered/N200DL-1997-04-14), registration cancelled 1997-04-14, S/N TK34 (OpenAirDocs) - Reported make and model: BEECH 58TC - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Category: Airplane - Serial number: TK-34 - Airframe hours: 2114 - Engines: CONTINENTAL TSIO-520-WB 325 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Callahan, Joel T. - Registered owner: Callahan, Joel T. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 18, 1994, 4 hours before - Departed: AL15 - Destination: MEI, MERIDIAN, MS - Airport: AL15, Jack Edwards, runway 27, 5,400 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 1,200 total, 600 in this make and model, 1,200 as pilot in command, 10 in the last 90 days, 6 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 10 knots, gusting 18 - Visibility: 6 statute miles - Lowest ceiling: 2,200 ft broken - Temperature: 77 °F, dew point 68 °F - Altimeter: 30.00 inHg - Observed at: NPA, 19 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19940327006569A](https://openairdocs.org/incident/19940327006569A), Mar 27, 1994: Beech 58, Gulfshores, AL, Destroyed, 1 fatal. Baggage door came open on climbout. Circled to land. Improper control action. Stalled base to final. Door not locked From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.