# NTSB CHI02IA116: Beech 200, N26SJ, Hillsdale, WI, April 22, 2002 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: April 22, 2002, 17:25 local (22:25 UTC) - Place: Hillsdale, WI - Coordinates: 45.250656, -91.810653 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.2507&lon=-91.8107&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 9 uninjured - Status: Completed, report November 25, 2003 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 54611 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02IA116 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54611/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54611 - Page: https://openairdocs.org/ntsb/CHI02IA116 ## Probable cause The fatigue failure of the passenger/crew door latch pin during cruise flight. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - door - fatigue (cause) - Decompression, cruise ## 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 (not matched to a registry record) - Reported make and model: Beech 200 - Category: Airplane - Serial number: BE592 - Airframe hours: 6352.3 - Engines: 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 As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; injuries: none; 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 - Co-pilot; age 68; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20020422011999I](https://openairdocs.org/incident/20020422011999I), Apr 22, 2002: Beech 200BEECH, Hillsdale, WI, Minor damage. (-23) On 04/22/02 a BE-200, N26SJ, departed on a flight from st. paul downtown holman field, Minnesota, at 1715 CDT, enroute to outagamie county regional… ## Docket (9 files) The files NTSB released with the investigation on September 10, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54611. 11.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 663 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434208&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Materials Laboratory 15 - Factual Report of Group Chairman (item 2, .PDF, 28 photos, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40160732&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Record of Interview and Witness Statements (item 3, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434209&FileExtension=.PDF&FileName=Record%20of%20Interview%20and%20Witness%20Statements-Redacted.PDF - Weather Information (item 4, .PDF, 463 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40196227&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Flight Manifests (item 5, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434210&FileExtension=.PDF&FileName=Flight%20Manifests-Redacted.PDF - Maintenance Records (item 6, .PDF, 353 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434211&FileExtension=.PDF&FileName=Maintenance%20Records-Redacted.PDF - Service Difficulty Reports (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40196230&FileExtension=.PDF&FileName=Service%20Difficulty%20Reports-Master.PDF - Airplane Maintenance & Parts Manual For Door (item 8, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40196231&FileExtension=.PDF&FileName=Airplane%20Maintenance%20%26%20Parts%20Manual%20For%20Door-Master.PDF - NTAP Data (item 9, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40196232&FileExtension=.PDF&FileName=NTAP%20Data-Master.PDF 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.