# NTSB DCA89MA035: McDonnell Douglas DC-9-33F, N931F, Saginaw, TX, March 18, 1989 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: March 18, 1989, 02:16 local (08:16 UTC) - Place: Saginaw, TX - Location: 32.8657° N, 97.3657° W: Placed by OpenAirDocs: center of Saginaw, TX, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=32.8657&lon=-97.3657&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report June 10, 1991 - Report: Board-adopted at Board Meeting - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 15918 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA89MA035.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15918/pdf - Board report AAR9002 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9002.pdf - Page: https://openairdocs.org/ntsb/DCA89MA035 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, standing - pre-flight - maintenance,service bulletin/letter - not followed, company/operator management (contributing factor) - inadequate surveillance of operation, faa(organization) (contributing factor) - door,cargo/baggage - not secured - electrical system,electric switch - failure,partial - warning system(other) - inoperative - procedures/directives - inadequate, company/operator management (contributing factor) - insufficient standards/requirements,aircraft, faa(organization) (contributing factor) - Miscellaneous/other, takeoff - initial climb - door,cargo/baggage - disengaged (contributing factor) - Loss of control - in flight, approach - vfr pattern - base leg/base to final - reason for occurrence undetermined (cause) - aircraft manuals,procedure information - inadequate (contributing factor) - procedures/directives - inadequate, manufacturer (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## 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](https://openairdocs.org/deregistered/N931F-2018-02-26), registration cancelled 2018-02-26, S/N 47192, built 1968 (OpenAirDocs) - Reported make and model: McDonnell Douglas DC-9-33F - Registry model: [Douglas DC-9-33F](https://openairdocs.org/model/douglas-dc-9-33f) (registry code 302207A) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT8D-9 series](https://openairdocs.org/engine/pratt-whitney-jt8d-9-series) (registry code 52048, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 47192 - Airframe hours: 41931 - Engines: P&W JT8D-9A 14500 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; 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 (OpenAirDocs). - [Accident 19890318004049A](https://openairdocs.org/incident/19890318004049A), Mar 18, 1989: Doug DC933F, Fort Worth, TX, Destroyed, 2 fatal. Main cargo door opened on takeoff. Loss of control. 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.