CHI08LA272

NTSB accident investigation · Socata TB-20 Trinidad · Cassville, WI · September 3, 2008

Accident · FatalLimited investigationFinal report
Date
September 3, 2008, 15:53 local (20:53 UTC)
Place
Cassville, WI
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N597TBSocata TB-20 Trinidad
Defining event
Approach-VFR go-around: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report December 29, 2009
Report
Approved by Office Director
Parties
Federal Aviation Administration, EADS Socata North America, Inc.
FAA report
20080903850379A
Case key
68998

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

On this page

Probable cause

The left seat pilot's failure to maintain control of the airplane during a go-around and the inadvertent in-flight opening of the cabin door for undetermined reasons. Contributing to the accident was the distraction of the door opening.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Doors: passenger/crew doorsAircraft › Aircraft structures · Not specifiedSocata TB-20 TRINIDAD: 1 caseAll aircraft: 86 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedSocata TB-20 TRINIDAD: 2 casesAll aircraft: 1,269 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotSocata TB-20 TRINIDAD: 1 caseAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Two pilots, who were enrolled in an aviation training program, preflighted the airplane for a flight that was to pick up a friend at the destination airport. After departure, the right cabin door opened for reportedly unknown reasons, and was then held closed by the right seat pilot. The left seat pilot diverted to a nearby airport. During the approach the left seat pilot elected to perform a go-around because the approach "didn't look good." During the go-around, the door reopened, and the airplane rolled to the right and impacted the ground. The right seat pilot was fatally injuried. The airplane was equipped with gull wing type doors, which do not open against the direction of the relative airflow. The in-flight opening of a cabin door is not listed as an emergency in the Pilot's Information Manual and flight with a door open was not tested by the airplane manufacturer. Furthermore, flight is prohibited with a door being open or ajar. The airplane was consumed by fire and only portions of the door assemblies were recovered.

Factual narrative

HISTORY OF FLIGHT On September 3, 2008, at 1553 central daylight time, a Socata TB-20 Trinidad, N597TB, received substantial damage on impact with terrain and post impact fire near Cassville, Wisconsin. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was not operating on a flight plan. The commercial pilot sustained serious injuries, and the private pilot sustained fatal injuries. There were no ground injuries. The flight originated from Dubuque Regional Airport (DBQ), Dubuque, Iowa, and was en route to Prairie du Chien Airport (PDC), Prairie du Chien, Wisconsin, when it diverted to Cassville Municipal Airport (C74), Cassville, Wisconsin. The fixed base operator's line worker, who refueled the accident airplane, was scheduled to work from 1430-1800 on the day of the accident. He stated that he arrived at work at 1430 and refueled the airplane at 1530. According to fuel records, the airplane was fueled about 1530. The line worker did not see the accident pilots and estimated that the airplane took off about 1/2 hour after it was refueled. Air traffic control transcripts were requested for the accident flight; however, these transcripts stated that N597TB was cleared for takeoff from DBQ at 1353:22 and there were no further radio transmissions by N597TB after acknowledging its takeoff clearance at 1353:28. The left seat pilot stated that he and the right seat pilot preflighted the airplane and planned to pick up a friend at PDC. According to the left seat pilot, the right cabin door opened in flight after an unknown amount of time had elapsed after takeoff. The right seat pilot then held the door closed, and the left seat pilot decided to divert to C74 (about 21 nautical miles northwest of DBQ). The left seat pilot stated that the approach to C74 "didn't look good" so he performed a go-around during which the right cabin door opened and the airplane rolled to the right. The left seat pilot stated that he "lost control" of the airplane and did not know whether the airplane stalled. He did not know what caused the door to open in-flight. PERSONNEL INFORMATION The left seat pilot was enrolled in the University of Dubuque's Aviation Program. He held a commercial pilot certificate with airplane single-engine land and instrument airplanes ratings. He accumulated a total flight time of 329 hours of which 53 hours were in Socata TB-20 Trinidad airplanes. The left seat pilot stated that he received flight instruction from a non University of Dubuque flight instructor pertaining to an airplane door opening in flight. During that instruction, a Cessna airplane was used and the door was opened in-flight. The right seat pilot was enrolled in University of Dubuque's Aviation Program in the commercial airplane course. He held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He accumulated a total flight time of about 181 hours, of which 2.1 hours were in the TB-20. Hehad not completed 10-hours of training within the commercial curriculum to receive an instructor sign off that would have allowed him to be checked out in the TB-20. AIRCRAFT INFORMATION The 1997 TB-20, serial number 1817, was equipped with gull-wing type doors made of composite for airplane serial numbers 2000 - 9999 or metal for serial numbers 1- 9999. The doors articulate around a hinge on the top of the fuselage and the doors opening and closing are slowed by a compensating cylinder located on the rear part of the door. According to the manufacturer's representative, the TB-20 airplane had not been flight tested with an open cabin door. The Pilot's Information Manual, Section 2, Limitations, Use of Doors, states, "Flight with doors open and ajar is prohibited." WRECKAGE AND IMPACT INFORMATION The main wreckage was resting between two motel cottages and about 500 feet from the approach end of runway 11 (3,000 feet by 50 feet, asphalt) at C74. The airplane was in an upright position on a tail to nose heading of about 140 degrees. The airplane and the two cottages were consumed by fire. Slash marks consistent with propeller strikes were noted in the motel driveway. The landing gear was extended and the flap jack screw extension equated to a 10 degree flap extension. The fuel selector was in the right fuel tank position. The right hand door hinge assembly was attached to the remaining fuselage and door. Only one of four door hook assemblies was found. The door hook assembly was separated from the door and within the main wreckage. The door hook assembly had two of the mounting screws attached to a portion of the remaining door. Each screw had three washers in place. The door hook assembly spring was in place. Only one of four access door mechanism latching ring assembly was found. The latch ring was of metal construction and fracture surfaces within the assembly were granular in appearance consistent with overload. TESTS AND RESEARCH Federal Aviation Administration (FAA) aircraft registry records show that there are 23 airplanes registered to the University of Dubuque, 4 of which are Socata TB-20 Trinidad airplanes. The Socata TB-20 Trinidad airplanes are registered as: N597TB, S/N 1817 N1866S, S/N 1866 N1887S, S/N 1887 N1909S, S/N 1909 According to the airplane manufacturer's representative, N597TB was equipped with steel door hook assemblies during its manufacture. According to the University's Director of Maintenance for the aviation program, the other Socata TB-20 door hook assemblies were checked using a magnet to determine if they were steel assemblies. All of the airplanes were reportedly equipped with steel door hook assemblies. The Director of Maintenance stated that there were no previous reports of cabin doors opening in flight on any of the TB-20s. The University's maintenance procedures make use of "squawk" sheets that are located in the aircraft dispatch book. The aircraft dispatch book was not recovered from the main wreckage andreportedly no archive of airplane squawk sheets or maintenance discrepancies is kept by the University. The University does not voluntarily submit reports to the FAA Service Difficulty Reporting (SDR) database. Unlike commercial operators, the University is not required to retain aircraft maintenance discrepancies and submit SDRs. A query of the Federal Aviation Administration Service Difficulty Reports for TB20 airplanes on November 25, 2008, yielded 34 records with only one relating to a cabin door.

Aircraft

Registration
N597TB
Reported as
Socata TB-20 Trinidad
Category
Airplane
Serial number
1817
Airframe hours
3,912
Engine
Lycoming IO-540-C4D5D, 250 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Last inspection
100 hour · June 19, 2008
Departed
DBQ · Dubuque, IA
Destination
PDC · Prairie du Chie, WI
Airport
C74 · Cassville Municipal Airport, runway 11, 3,000 × 50 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
20
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
July 25, 2008
Seat
Left
Flight hours
329 total · 53 in this make and model · 263 as pilot in command · 18 in the last 90 days · 4 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 55 °F
Altimeter
30.00 inHg
Observed at
PVB, 23 nm away

Docket · 63

The files NTSB released with the investigation on August 18, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 570 KBPilot's StatementItem 2 · .PDF · 58 KBRecord of InterviewItem 3 · .PDF · 26 KBWeatherItem 4 · .PDF · 145 KBATC TranscriptItem 5 · .PDF · 178 KBAircraft RegistryItem 6 · .PDF · 83 KBService Difficulty ReportsItem 7 · .PDF · 461 KBParts ManualItem 8 · .PDF · 94 KBMaintenance ManualItem 9 · .PDF · 151 KBMaintenance ProceduresItem 10 · .PDF · 165 KBFuel RecordsItem 11 · .PDFStatement of Party Representatives to NTSB InvestigationItem 12 · .PDF · 438 KBPhoto 1. Accident Site (FAA Photo)Item 13 · .PDF · 6.4 MBPhoto 2. Accident Site (FAA Photo)Item 14 · .PDF · 5.0 MBPhoto 3. Accident Site (FAA Photo)Item 15 · .PDF · 5.4 MBPhoto 4. Accident Site (FAA Photo)Item 16 · .PDF · 5.3 MBPhoto 5. Accident Site (FAA Photo)Item 17 · .PDF · 5.0 MBPhoto 6. Accident Site (FAA Photo)Item 18 · .PDF · 5.3 MBPhoto 7. Accident Site (FAA Photo)Item 19 · .PDF · 5.3 MBPhoto 8. Accident Site (FAA Photo)Item 20 · .PDF · 5.4 MBPhoto 9. Accident Site (FAA Photo)Item 21 · .PDF · 4.9 MBPhoto 10. Accident Site (FAA Photo)Item 22 · .PDF · 5.3 MBPhoto 11. Accident Site (FAA Photo)Item 23 · .PDF · 5.5 MBPhoto 12. Accident Site (FAA Photo)Item 24 · .PDF · 5.4 MBPhoto 13. Accident Site (FAA Photo)Item 25 · .PDF · 4.9 MBPhoto 14. Accident Site (FAA Photo)Item 26 · .PDF · 4.6 MBPhoto 15. Accident Site (FAA Photo)Item 27 · .PDF · 4.3 MBPhoto 16. Accident Site (FAA Photo)Item 28 · .PDF · 4.2 MBPhoto 17. Accident Site (FAA Photo)Item 29 · .PDF · 4.7 MBPhoto 18. Accident Site (FAA Photo)Item 30 · .PDF · 4.7 MBPhoto 19. Accident Site (FAA Photo)Item 31 · .PDF · 4.7 MBPhoto 20. Accident Site (FAA Photo)Item 32 · .PDF · 5.0 MBPhoto 21. Accident Site (FAA Photo)Item 33 · .PDF · 4.8 MBPhoto 22. Door PartsItem 34 · .PDF · 975 KBPhoto 23. Door PartsItem 35 · .PDF · 1.0 MBPhoto 24. Door PartsItem 36 · .PDF · 894 KBPhoto 25. Door PartsItem 37 · .PDF · 925 KBPhoto 26. Door PartsItem 38 · .PDF · 842 KBPhoto 27. Door PartsItem 39 · .PDF · 766 KBPhoto 28. Door PartsItem 40 · .PDF · 767 KBPhoto 29. Door PartsItem 41 · .PDF · 920 KBPhoto 30. Door PartsItem 42 · .PDF · 938 KBPhoto 31. Door PartsItem 43 · .PDF · 824 KBPhoto 32. Door PartsItem 44 · .PDF · 931 KBPhoto 33. Door PartsItem 45 · .PDF · 973 KBPhoto 34. Door PartsItem 46 · .PDF · 884 KBPhoto 35. Door PartsItem 47 · .PDF · 791 KBPhoto 36. Door PartsItem 48 · .PDF · 818 KBPhoto 37. Door PartsItem 49 · .PDF · 878 KBPhoto 38. Door PartsItem 50 · .PDF · 859 KBPhoto 39. Door PartsItem 51 · .PDF · 965 KBPhoto 40. Door PartsItem 52 · .PDF · 878 KBPhoto 41. Door PartsItem 53 · .PDF · 954 KBPhoto 42. Door PartsItem 54 · .PDF · 869 KBPhoto 43. Door PartsItem 55 · .PDF · 985 KBPhoto 44. Door PartsItem 56 · .PDF · 950 KBPhoto 45. Door PartsItem 57 · .PDF · 922 KBPhoto 46. Door PartsItem 58 · .PDF · 864 KBPhoto 47. Door PartsItem 59 · .PDF · 844 KBPhoto 48. Door PartsItem 60 · .PDF · 945 KB
All 63 files on NTSB’s docket

FAA reports on this event · 1

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