- Date
- March 18, 1989, 02:16 local (08:16 UTC)
- Place
- Saginaw, TX
- Injuries
- 2 fatal
- Damage
- Destroyed
- Phase of flight
- Standing
- Aircraft
- N931FMcDonnell Douglas DC-9-33F
- Weather
- Visual (VMC) · Night/dark
- Status
- Completed · report June 10, 1991
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- NTSB office
- Major Investigations Division
- Safety recommendations
- Yes
- FAA report
- 19890318004049A
- Case key
- 15918
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 loss of control of the airplane for undetermined reasons following the inflight opening of the improperly latched cargo door. Contributing to the accident were: inadequate procedures used by evergreen airlines and approved by the FAA for preflight verification of cargo door security, evergreen's failure to mark properly the airplane's external cargo door lockpin manual control handle, and the failure of Mcdonnell Douglas to provide flightcrew guidance and emergency procedures for an inflight opening of the cargo door. Also contributing to the accident was the failure of the FAA to mandate modification to the door-open warning system for DC-9 cargo-configured airplanes, given the previous known occurrences of inflight door openings.
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.
Analysis
As the acft rotated for tkof, the cargo door (cd) opened. The crew contd tkof & turned to a dwnwnd leg to lnd on rwy 17.they answered twr instrns to rprt 'base.' This was the last tmtn they rcvd, tho they tried svrl times to ctc twr or apch ctl. As the acft turned on base leg (with a tail wnd at tfc pattern alt), radar data indcd acft would cross the rwycenterline. Radar ctc was then lost; the acft crashed in a steep dscnt. There was evidence that bfr flt, the 1st officermisinterpreted the external lockpin manual ctl handle psn to mean the cd was locked (as a result of incorrect markings).also, there was a malfunction of a cd open warning lgt sw, preventing opn of the warning lgt. Additionally, svrl svc bulletins (sb's) concerning the cd had not been complied with. These sb's would have provided an extra safety feature of the cd warning lgt sys, a door venting sys & a lockpin viewing window for the door. There was no emerg proc or specific guidance to aid DC-9 crews for this situation, though svrl cd openings had occurred. (See: NTSB/AAR-90/02)
Aircraft
- Registration
- N931F
- Reported as
- McDonnell Douglas DC-9-33F
- Category
- Airplane
- Serial number
- 47192
- Airframe hours
- 41,931
- Engine
- P&W JT8D-9A, 14,500 lbs thrust, turbo fan
- Damage
- Destroyed
- Fire
- On-Ground
- Flight
- Part 121
- Airworthiness certificate
- Standard, Transport; Standard, Normal
- Last inspection
- Continuous airworthiness · March 13, 1989 · 16 hours before
- Departed
- FWH
- Destination
- TIK · Oklahoma City, OK
- Flight plan
- IFR
- Airport
- FWH · Carswell Afb, runway 17, 12,000 × 300 ft, concrete
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
- 42
- Certificates
- Airline transport, Commercial
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--no waivers/lim.
- Seat
- Left
- Flight hours
- 7,238 total · 1,938 in this make and model · 4 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Night/dark
- Wind
- 320° at 6 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 66 °F
- Altimeter
- 30.00 inHg
- Observed at
- FWH, 8 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.