# NTSB DEN89FA141: Beech A36, N1778W, South Lake Taho, CA, June 19, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: June 19, 1989, 13:30 local (20:30 UTC)
- Place: South Lake Taho, CA
- Location: 38.9282° N, 119.9810° W: Placed by OpenAirDocs: center of South Lake Tahoe, CA, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=38.9282&lon=-119.9810&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report August 22, 1990
- Report: Approved by Office Director
- NTSB case key (mKey): 17591
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN89FA141
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/17591/pdf
- Page: https://openairdocs.org/ntsb/DEN89FA141

## Probable cause

THE PILOT'S FALURE TO MAINTAIN ADEQUATE AIRSPEED AFTER TAKEOFF DUE TO DIVERTED ATTENTION TOWARD AN OPEN ACFT DOOR.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, takeoff - initial climb
  - door,passenger - open (contributing factor)
  - airspeed - not maintained, pilot in command (cause)
  - diverted attention, pilot in command (cause)
  - door,passenger - failure,total (contributing factor)
  - stall - inadvertent, pilot in command (cause)
- In flight collision with terrain/water, takeoff - initial climb

## Analysis

THE PLT ABORTED THE FIRST TAKEOFF ATTEMPT DUE TO THE DOOR OPENING. ON THE SECOND ATTEMPT THE ACFT CLIMBED TO APRX 300 FT, TURNED 90 DEGS LEFT THEN BACK TO THE RWY HEADING. THE NOSE DESCENDED AND THE ACFT IMPACTED A FIELD IN A VERTICAL DIVE. FIRE BEGAN APX 15 SECONDS FOLLOWING IMPACT AND THE ACFT WAS CONSUMED BY FIRE. EXAMINATION OF THE WRECKAGE REVEALED THE CABIN DOOR TO HAVE SEPARATED FROM THE ACFT AT IMPACT AND THE TOP LATCH, A 'J' HOOK, WAS FRACTURED AND MISSING.

## Aircraft

- Registration: [N1778W](https://openairdocs.org/deregistered/N1778W-2012-08-13), registration cancelled 2012-08-13, S/N E-378, built 1972 (OpenAirDocs)
- Reported make and model: Beech A36
- Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: E-378
- Airframe hours: 3305
- Engines: CONTINENTAL IO-520-BA10B 285 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Registered owner: Delta W, Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 8, 1989, 43 hours before
- Departed: TVL
- Destination: PAO, PALO ALTO, CA
- Airport: TVL, Lake Tahoe, runway 18, 8,544 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 57; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,790 total, 890 in this make and model, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 170° at 13 knots
- Visibility: 50 statute miles
- Lowest ceiling: none
- Temperature: 73 °F, dew point 27 °F
- Altimeter: 30.00 inHg
- Observed at: TVL, 1 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 19890619016149A](https://openairdocs.org/incident/19890619016149A), Jun 19, 1989: Beech A36, South Lake Taho, CA, Destroyed, 1 fatal. On climbout, stalled in a turn, crashed and burned. Air density factor.

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.

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