CHI02IA116

NTSB incident investigation · Beech 200 · Hillsdale, WI · April 22, 2002

Incident · No injuriesIncident investigationFinal report
Date
April 22, 2002, 17:25 local (22:25 UTC)
Place
Hillsdale, WI
Injuries
9 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N26SJBeech 200
Weather
Visual (VMC) · Day
Status
Completed · report November 25, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20020422011999I
Case key
54611

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The fatigue failure of the passenger/crew door latch pin during cruise flight.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise
Door - fatigueCause
DecompressionCruise

Analysis

The on-demand passenger flight was cruising at flight level 190 when the passenger/crew door separated from the airframe. Visual meteorological conditions with no reported turbulence prevailed at the time of the incident. The door was recovered in the locked position. Examination of the door revealed a fatigue fracture of the upper aft latch bolt. There were no indications of damage to the door frame and latch plates.

Factual narrative

History of flight

On April 22, 2002, at 1725 central daylight time, a Beech 200, N26SJ, operated by Flying Dollar Air Incorporated as a subcontract flight for Max Air, received minor damage when the passenger/crew door departed the airplane during cruise at flight level (FL) 190, near Hillsdale, Wisconsin. The flight crew performed an emergency landing at the Chippewa Valley Regional Airport (EAU), Eau Claire, Wisconsin. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 135 passenger flight was operating on an instrument flight rules flight plan. The two flight crewmembers and seven passengers were uninjured. The flight departed from the St. Paul Downtown Holman Field Airport (STP), St. Paul, Minnesota, at 1715, and was en route to the Outagamie County Regional Airport, Appleton, Wisconsin.

The pilot said that the copilot told him that he latched the door, and the door handle was rotated to the over center position. The copilot illuminated the door light to check that the latch pins were in place. The annunciator for the door was not illuminated once the door was closed. He said the airplane was cruising at an indicated airspeed of 195-200 knots and an outside air temperature of -16 degrees Celsius. He also said that the cabin differential pressure indicated 3,200 feet and 6.1 psi. There was no air turbulence. At 1735, the airplane was approximately 35-40 nautical miles (nm) northwest of EAU at FL 190 when the door departed the airplane. The door annunciator light illuminated and remained illuminated for the duration of the flight.

The passenger/crew door has two forward latch bolts, two aft latch bolts, and two upper hooks. The upper latch bolts are ramped to draw the door into place as they are extended. When the upper latch bolts are extended, the door frame rollers must rest a minimum of 0.12 inches past the tangent portion of the latch bolts. The structural limitation for the forward and aft latch bolts are 6,000 hours.

Beech 200 service difficulty reports (SDRs), from 1974 to April 24, 2002, include 11 records of cabin and cargo door failures. Of the 11 records, 8 involved cabin door separations from the airframe. Additional SDRs relating to the Beech 100, 99, and 90 cabin doors are included in this report.

Logbook entries show that on September 25, 2000, at an airplane total time in service of 5,946.2 hours, four cabin door pins (part numbers: 50 430177-5 and 50-430018-4) were replaced. The airplane accumulated 6,352.6 hours at the time of the accident.

The passenger/crew door was found in an agricultural field approximately 30 nm northwest of EAU. The door handle and latch bolts were in the locked position. The upper aft latch bolt was broken off and lying within door structure. The fuselage door frame and latch plates were undamaged. The door was sent to the National Transportation Safety Board's Materials Lab. Visual and scanning electron microscope examination of the latch bolt confirmed that fatigue fracture within the threaded portion of latch bolt was the fracture mode.

Aircraft

Registration
N26SJ
Reported as
Beech 200
Category
Airplane
Serial number
BE592
Airframe hours
6,352.3
Engine
Pratt & Whitney PT6A-41, 850 horsepower, turbo prop
Damage
Minor damage
Flight
Part 135
Registered owner
Flying Dollar Air Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 17, 2002 · 5.5 hours before
Departed
STP · St Paul, MN
Destination
ATW · Appleton, WI
Flight plan
IFR

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Injuries
None
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
January 13, 2002
Seat
Left
Flight hours
5,540 total · 425 in this make and model · 3,470 as pilot in command · 109 in the last 90 days · 32 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
68
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
March 28, 2002
Seat
Right
Flight hours
21,800 total · 850 in this make and model · 21,500 as pilot in command · 640 in the last 90 days · 21 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 3 knots
Visibility
10 statute miles
Lowest ceiling
3,800 ft overcast
Temperature
37 °F, dew point 27 °F
Altimeter
30.12 inHg
Observed at
EAU, 30 nm away

Docket · 9

The files NTSB released with the investigation on September 10, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.5 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.