# NTSB DFW06FA180: Beech C24R, N78MB, Virginia Beach, VA, July 11, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 11, 2006, 11:32 local (15:32 UTC) - Place: Virginia Beach, VA - Coordinates: 36.874721, -76.179168 - Nearby events: https://openairdocs.org/map.md?lat=36.8747&lon=-76.1792&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 29, 2007 - Report: Approved by Office Director - Parties: FAA/FSDO, Raytheon Aircraft Company, Textron Lycoming - NTSB case key (mKey): 64080 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DFW06FA180 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/64080/pdf - Page: https://openairdocs.org/ntsb/DFW06FA180 ## Probable cause The pilot's failure to maintain airspeed, which resulted in an inadvertent stall/spin while maneuvering at a low altitude. Contributing was the pilot's diverted attention to an open door. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - base turn - diverted attention, pilot in command (contributing factor) - door,cargo/baggage - open - airspeed - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with object, descent - uncontrolled - object - tree(s) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The aircraft stalled while in the traffic pattern and struck trees, then crashed into the ground. Shortly after takeoff, the 1,493-hour instrument rated private pilot informed air traffic control that a "door had opened" and that he needed to return to the airport. The pilot leveled off at an altitude of 200 feet msl at an airspeed of 100 knots and proceeded to make two left turns to enter the downwind leg of the traffic pattern. Radar data revealed that while on the downwind leg, the airplane's ground speed decelerated to 70 knots. When the airplane was about one-mile beyond the end of the runway, it began another left turn before it collided with trees in the backyard of a private residence. A witness heard a large shaking sound similar to a semi-type truck braking down in front of his home. He then looked up and saw the airplane flying "very slow" about 20-feet-high above the tree line. The witness demonstrated with a model airplane that the airplane had a slightly nose-high attitude and was in a shallow left turn. The airplane was shaking violently. The witness then maneuvered the model airplane so it simultaneously rolled rapidly to the left (inverted) and the nose of the airplane dropped toward the ground. The witness said he lost sight of the airplane as it descended into the trees. Raytheon released a Mandatory Service Bulletin and a Safety Communique regarding doors opening in flight on this and other model airplanes in 1990. A review of the accident airplane's maintenance logbook revealed that the Service Bulletin was initially complied with in 1991, which required a Cabin Door Latching Warning placard to be placed on both of the main cabin door windows. On December 14, 1995, both the left and right cabin windows were removed and replaced; however, there was no entry in the logbook regarding the replacement of the placard. On June 13, 2003, the right cabin window was again removed and replaced; however, there was no entry that the placard had been installed. Examination of both the left and right cabin windows at the accident site revealed that the Cabin Door Latching Warning placard was not installed on either window as directed in the Service Bulletin. The airplane came to rest in the backyard of a residence in the inverted position. The flaps were found in the retracted position, and the landing gear were found in the fully retracted position. No anomalies were found with the airframe or the engine that could have prevented normal flight operations. The winds at the time of the mishap were reported from 230 degrees at 9 knots. ## Factual narrative HISTORY OF FLIGHT On July 11, 2006, at 1132 eastern daylight time, a single-engine Beech C24R airplane, N78MB, sustained substantial damage when it collided with trees and terrain following a loss of control while attempting to return to land on Runway 32 at the Norfolk International Airport (ORF), near Norfolk, Virginia. The instrument rated private pilot, his passenger, and two dogs sustained fatal injuries. The airplane was registered to, and operated by the pilot. An instrument flight rules (IFR) flight plan was filed for the cross-country flight destined for the Hilton Head Island Airport (HXD), near Hilton Head, South Carolina. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91. A review of the air traffic control communications revealed the flight was cleared for take-off on Runway 32 (a 4,875-foot-long, by 150-foot-wide asphalt runway) at 1127:04. Less than a minute later, the pilot contacted the control tower and stated "need to come around and land again...I got a door open." A tower controller then instructed the pilot to turn left and enter the downwind leg of the traffic pattern for Runway 32, and the pilot acknowledged. The controller then asked the pilot if he was able to make a short approach, to which the pilot replied that he could. The controller then cleared the pilot to land on Runway 32. A few moments later, the tower controller advised the pilot to extend the downwind leg due to traffic on final approach, and that the tower would inform him when he could turn onto the base leg. The pilot again acknowledged the radio transmission. At 1129:43, the tower controller instructed the pilot to turn onto the base leg, and again, the pilot acknowledged. This was the last radio communication received from the pilot. A review of the radar data indicated the airplane departed runway 32 and leveled-off at an altitude of 200 feet mean sea level (msl), while maintaining a ground speed of 100 knots. Radar data revealed that the airplane executed a left turn to a southeasterly heading and flew parallel to the runway. Radar data also revealed that as the airplane proceeded on this heading, its ground speed decreased to 70 knots. When the airplane was about one-mile beyond the end of the runway, another left turn was initiated toward the northeast before the radar data ended at 1130. A witness, who was working in his garage, reported that he heard "a large shaking sound which sounded like a semi-type truck braking down in front of [his] house." The witness then looked up and saw the airplane flying "very slow" about 20-feet-high above the tree line. The airplane was shaking and it sounded like it was losing power. The witness was provided a model airplane to demonstrate the flight attitude of the airplane. The witness demonstrated that the airplane had a slightly nose-high attitude and was in a shallow left hand turn. The airplane was shaking violently. The witness then maneuvered the model airplane so it simultaneously rolled rapidly to the left (inverted) and the nose of the airplane dropped toward the ground. The witness further stated that he lost sight of the airplane as it descended into the trees. PERSONNEL INFORMATION The pilot held a private pilot certificate for airplane single engine land, with an instrument rating. His last Federal Aviation Administration (FAA) third class medical was issued on January 27, 2005. At that time the pilot reported he had accumulated a total of 1,300 flight hours. A review of the pilot's logbook revealed that his last entry was made on June 10, 2006. At that time he had logged a total of 1,493.3 hours. METEOROLOGICAL INFORMATION Weather reported at the Norfolk International Airport at 1151 was wind from 230 degrees at 9 knots, 10 miles visibility, clear skies, 89 degrees Fahrenheit, 66 degrees Fahrenheit, and a barometric pressure setting of 30.11 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in the inverted position in the backyard of a private residence on a heading of 185 degrees, at an elevation of approximately 26 feet msl. The accident occurred during the hours of daylight approximately 36 degrees, 52 minutes, north latitude, and 076 degrees, 10 minutes west longitude. The initial impact point was a stand of approximately 70-foot-high trees. From the point of initial impact to where the main wreckage came to rest was approximately 116 feet. Examination of the trees found along the wreckage path revealed numerous impact marks that got progressively lower in the direction of the main wreckage on an approximate angle of 42 degrees. The area around the wreckage was permeated with the odor of aviation gasoline. Found along the wreckage path were the left wing, the landing light, the left main wheel, the rudder, stabilator, the right aileron, and the right wing tip. Also found along the wreckage path were numerous downed trees limbs. Some of the branches exhibited angular cuts with black paint transfer marks. The main wreckage consisted of the right wing, propeller, engine, cockpit, fuselage, empennage, and the vertical stabilizer. The leading edges of both wings and the stabilator exhibited impact damage. Flight control continuity was established for all primary flight control surfaces. Examination of the flap actuator revealed the flaps were fully retracted. The landing gear was also found in the retracted position. The elevator trim actuator exhibited impact damage and a measurement could be obtained. The left main cabin door remained attached to the fuselage; was unlatched and exhibited impact damage. Due to this damage, the door's internal and external handles could not be functionally tested; however, the latching mechanisms were intact and undamaged. The right main cabin door also remained attached to the fuselage; was unlatched, and exhibited some impact damage. Both the internal and external handles were tested and they functioned normally and the latching mechanisms were intact and undamaged. The cargo door (aft left side of fuselage) was also found open and exhibited impact damage. The section of empennage that surrounded the door also exhibited impact damage. The external handle was locked from the outside, but the internal handle functioned normally when the locking pin was pulled. Examination of the latching mechanisms revealed they were intact and undamaged. The engine remained attached to the airframe. The engine was manually rotated via the propeller flange, and valve train continuity and compression was established on each cylinder. The spark plugs were removed and appeared normal. Both magnetos were removed, and the ignition leads were cut at the terminals. Spark was produced to all leads when manually rotated. The fuel nozzles were removed and were absent of debris. Fuel was present in the engine driven fuel pump, fuel injector servo, and the fuel manifold. Fuel injector servo inlet screen was absent of debris. Oil was present in the engine. The oil filter was removed and the element was absent of debris. The oil suction screen was also absent of debris. The propeller governor was removed and the oil screen was absent of debris. The two-bladed propeller remained attached to the engine. Both blades were twisted and exhibited s-bending; however, only one blade was loose in the hub. AIRCRAFT INFORMATION The airplane, serial number MC-645, was a four-seat, single-engine, low-wing airplane. Its last annual inspection was completed on August 22, 2005, at a total airframe time of 4,834.77 hours. Prior to departure, the pilot purchased 12.9 gallons of 100 LL aviation fuel, which topped both fuel tanks for a total of 60 gallons. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted on the pilot on July 12, 2006, by the Virginia Medical Examiner's office, Norfol ## Aircraft - Registration: [N78MB](https://openairdocs.org/deregistered/N78MB-2007-08-22), registration cancelled 2007-08-22, S/N MC-645, built 1979 (OpenAirDocs) - Reported make and model: Beech C24R - Registry model: [Beech C24R](https://openairdocs.org/model/beech-c24r) (registry code 1151254) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: MC-645 - Airframe hours: 4834 - Engines: Textron Lycoming IO-360-A1B6 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: George Robert Schell - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2005 - Departed: ORF, Norfolk, VA - Destination: HXD, Hilton Head, SC - Flight plan: IFR - Airport: ORF, Norfolk International Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3; seat: left; toxicology performed; flight hours: 1,493 total, 1,200 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 9 knots - Visibility: 8 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 66 °F - Altimeter: 30.17 inHg - Observed at: ORF ## 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 20060711012199A](https://openairdocs.org/incident/20060711012199A), Jul 11, 2006: Beech C24R, Norfolk, VA, Destroyed, 2 fatal. (-23) Upon takeoff from runway 32 at Norfolk International Airport (korf), the pilot notified the tower a door had come open. He requested to return and land.… 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.