# NTSB ERA14LA218: Beech V35B, N702JS, Middlesboro, KY, May 2, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: May 2, 2014, 13:40 local (17:40 UTC) - Place: Middlesboro, KY - Coordinates: 36.606945, -83.738891 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.6069&lon=-83.7389&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report December 15, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, CMI, Textron Aviation - NTSB case key (mKey): 89155 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA218 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89155/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89155 - Page: https://openairdocs.org/ntsb/ERA14LA218 ## Probable cause The pilot's failure to maintain airplane control during the landing approach due to his diverted attention to the partially opened main cabin door and the unsecured dog. Contributing to the accident was the pilot's failure to securely latch the main cabin door before takeoff and to secure his dog. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech V35B, 1 case](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=1151548), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech V35B, 16 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151548), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech V35B, 4 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=1151548), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Incorrect use/operation (probable cause); cases with it: [Beech V35B, 2 cases](https://openairdocs.org/ntsb-findings/01035210/cases.md?model=1151548), [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01035210/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech V35B, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=1151548), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech V35B, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1151548), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech V35B, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151548), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-VFR pattern final: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech V35B, 20 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151548), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Beech V35B, 4 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=1151548), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## Analysis The private pilot departed in the airplane, which he had purchased that morning, with his dog onboard. According to the airplane's previous owner, who witnessed the accident, shortly after takeoff, the pilot announced over the common traffic advisory frequency that the "door popped open" and that he was returning to the airport. The witness further stated that, on final approach, about 30 feet above ground level, the airplane banked left, rolled wings level, flew perpendicular away from the runway, and impacted the ground in a flat attitude. The airplane subsequently became engulfed in flames. Postaccident examination of the airframe and engine did not reveal any abnormalities that would have precluded normal operation. Thermal damage around the main cabin door precluded determination of the main cabin door locking mechanism's position at the time of impact. It is likely that the pilot did not securely latch the main cabin door before takeoff and that the door partially opened in flight, which resulted in his decision to return to the departure airport. It is also likely that the pilot's dog was not in an animal carrier, which further distracted the pilot. As the pilot slowed the airplane for landing, his attention was likely more focused on the partially opened door and the dog than the landing, which resulted in his failure to maintain airplane control during the landing approach. ## Factual narrative HISTORY OF FLIGHT On May 2, 2014, about 1340 eastern daylight time, a Beech V35B, N702JS, collided with terrain during a landing attempt at Middlesboro-Bell County Airport (1A6), Middlesboro, Kentucky. The certificated private pilot sustained serious injuries and a dog sustained minor injuries. The airplane sustained substantial impact and thermal damage to both wings and fuselage. Visual meteorological conditions prevailed and no flight plan was filed for the flight. The airplane was registered to a private individual and operated by another private individual under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to an eyewitness, who was also the registered owner of the airplane on file with the Federal Aviation Administration (FAA), the pilot purchased the airplane the morning of the accident and flew with another private pilot prior to the accident flight. Shortly after departure, on the accident flight, the pilot announced on the common traffic advisory frequency that a "door popped open" and that he was returning to land. The eyewitness further stated that on final approach, about 30 feet above ground level, the airplane banked to the left, rolled wings level, flew perpendicular away from the runway, and impacted the ground in a flat attitude. The airplane subsequently became engulfed in flames, and the pilot extricated himself from the airplane with thermal injuries. PERSONNEL INFORMATION The pilot, age 71, held a private pilot certificate for airplane single-engine land, issued September 30, 1995, and a third class medical certificate issued February 21, 2006. The pilot's logbook was not provided to the investigation team at the time of this writing. On the pilot's February 21, 2006, medical application, he reported approximately 2300 total flight hours. AIRCRAFT INFORMATION The four-seat, low-wing airplane, serial number D-9603 was manufactured in 1974. It was powered by a Teledyne Continental Motors IO-550B. Review of the airplane maintenance logbook records showed and annual inspection was completed on May 1, 2014, at a recorded tachometer reading of 2250.5 hours, which correlated to an airframe total time of 5363.67 hours. The tachometer was observed at the accident site and indicated 2250.58 hours. According to an FAA inspector on scene, an FAA Aircraft Registration Form, No. 2120-0042, was located within the wreckage. The form was dated May 2, 2014, and listed the accident pilot as the registered owner. A Bill of Sale was also provided from the previous registered owner dated May 2, 2014, and indicated that the accident pilot had purchased the airplane from the registered owners. METEOROLOGICAL INFORMATION The 1335 recorded weather observation at 1A6, included wind from 270 degrees at 4 knots, 10 miles visibility, broken clouds at 5,500 feet above ground level, temperature 18 degrees C, dew point 4 degrees C; barometric altimeter 29.93 inches of mercury AIRPORT INFORMATION The airportis a publically owned airport and at the time of the accident did not have an operating control tower. The airport was equipped with one runway designated as runway 10/28. The runway was 3,631-foot-long by 75-foot-wide runway and was listed as "in good condition." The airport was 1,154 feet above mean sea level. WRECKAGE AND IMPACT INFOMRATION On-site examination of the wreckage by an FAA inspector and a representative from the airplane manufacturer revealed that the airplane impacted the paved portion of the displaced threshold of the intended landing runway with the left wing fiberglass fuel tip tank. The debris path was about 250 feet in length, from the initial impact point to the main wreckage, began about 90 feet prior to the runway displaced threshold, and was on a course of about 071 degrees. Along the debris path, 5 distinct ground scars were located in the ground, similar in appearance as propeller blade marks. The ground scars varied in distance between each other and were progressively increasing in distance. The distances from the first ground scar to the last ground scar was approximately 48 inches. Further examination revealed flight control continuity to all flight control surfaces and the ruddervator trim actuator extension was measured and found to be about one-half inch, which correlated to approximately 20 degree nose up trim position. Both wing flap actuators were measured and the measurements correlated to about a 30 degree flap position. Both main fuel tanks contained approximately 40 gallons of blue fluid similar in color and smell as 100 LL aviation fuel and both fiberglass wingtip tanks were breeched. The fuel selector valve was found in the right wing main fuel tank detent. The fuel system was free of debris and no abnormalities with the system were noted. All three landing gear assemblies, including the actuators, were found in the extended position and the landing gear selector handle, located in the cockpit, was found in the "DOWN" position. The cockpit and forward portion of the cabin, including the main cabin door, exhibited thermal damage consistent with postimpact fire. The thermal damage precluded examination of the door lock mechanism. No evidence existed in the wreckage that indicated there was any animal carrier to secure the dog. However, the investigation could not conclusively determine if the dog was in the front seat or some other location in the airplane at the time of the accident. TEST AND RESEARCH A postaccident examination of the engine, revealed thermal damage to the rear accessories as well as cables and hoses. The engine was mounted in an engine test cell, started on the first attempt, and operated at various power settings required of a newly manufactured engine. During the engine exam and test run, no anomalies were noted that would have precluded normal operation. For further information in regards to the engine examination please reference the "Engine Examination Report" located in thedocket for this accident case. ADDITIONAL INFORMATION The Pilot Operating Manual (POM) "BEFORE TAKE-OFF" checklist in Section II, "Normal Procedures" outlines the before takeoff procedures. The procedure states in part "….11. Doors and Windows – Secure…" In addition Section III "Emergency Procedures" states in part "Unlatched Door in Flight – If the cabin door is not locked it may come unlatched in flight. This may occur during or just after take-off. The door will trail in a position approximately 3 inches open but the flight characteristics of the airplane will not be affected. Return to the field in a normal manner. If practicable, during the landing flare-out have a passenger hold the door to prevent it from swinging open." According to the Hawker Beechcraft Corporation "Bonanza 35 Series Shop Manual" Section 7C, "Cabin and Baggage Compartment" states in part "…14 Windows and Doors -…Inspect doors for security of attachment. Check latching mechanism for proper engagement and ease of operation. Check that the rotation of the interior door handle without depressing the handle lock release button does not unlatch the door…" ## Aircraft - Registration: [N702JS](https://openairdocs.org/deregistered/N702JS-2016-08-30), registration cancelled 2016-08-30, S/N D-9603, built 1974 (OpenAirDocs) - Reported make and model: BEECH V35B - Registry model: [Beech V35B](https://openairdocs.org/model/beech-v35b) (registry code 1151548) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-9603 - Year built: 1974 - Airframe hours: 5364 - Engines: Tyledyne Continental Motors IO-550-B(5) 300 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2014, 0 hours before - Departed: 1A6, Middlesboro, KY - Airport: 1A6, Middlesboro-Bell County, runway 10, 3,631 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; flight hours: 2,300 total ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft broken - Temperature: 64 °F, dew point 39 °F - Altimeter: 29.93 inHg - Observed at: K1A6 ## 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 20140502020409A](https://openairdocs.org/incident/20140502020409A), May 2, 2014: Beech V35B, Middlesboro, KY, Destroyed. Upon take off the door of the aircraft popped open. The pilot attempted to close the door and return to the airport. The pilot was unable to secure the door… ## Docket (18 files) The files NTSB released with the investigation on October 1, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89155. 33.0 MB in all. - Memorandum of Record - Contact Attempts with Pilot (item 1, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417001&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Contact%20Attempts%20with%20Pilot-Master.PDF - Memorandum of Record - Eyewitness Interview Summaries (item 2, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417002&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20Eyewitness%20Interview%20Summaries-Master.PDF - Memorandum of Record - On Scene Examination (item 3, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417004&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20On%20Scene%20Examination-Master.PDF - Memorandum of Record – Middlesboro Weather (item 4, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417010&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20%E2%80%93%20Middlesboro%20Weather-Master.PDF - Email - Lockheed Martin Flight Service Station (item 5, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417003&FileExtension=.PDF&FileName=Email%20-%20Lockheed%20Martin%20Flight%20Service%20Station-Redacted.PDF - Wreckage Diagram (item 6, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417005&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Maintenance Logbooks (Excerpts) (item 7, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417006&FileExtension=.PDF&FileName=Maintenance%20Logbooks%20(Excerpts)-Redacted.PDF - Hawker Beechcraft Corporation – Bonanza 35 Series Shop Manual (Excerpt) (item 8, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417007&FileExtension=.PDF&FileName=Hawker%20Beechcraft%20Corporation%20%E2%80%93%20Bonanza%2035%20Series%20Shop%20Manual%20(Excerpt)-Master.PDF - Engine Examination Report (item 9, .PDF, 29 photos, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417008&FileExtension=.PDF&FileName=Engine%20Examination%20Report-Redacted.PDF - Hawker Beechcraft Corporation – Beech V35 Pilot Operating Manual (Excerpts) (item 10, .PDF, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417009&FileExtension=.PDF&FileName=Hawker%20Beechcraft%20Corporation%20%E2%80%93%20Beech%20V35%20Pilot%20Operating%20Manual%20(Excerpts)-Master.PDF - Aircraft Bill of Sale (item 11, .PDF, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417011&FileExtension=.PDF&FileName=Aircraft%20Bill%20of%20Sale-Redacted.PDF - Registered Owner Paperwork (item 12, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417012&FileExtension=.PDF&FileName=Registered%20Owner%20Paperwork-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417013&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417014&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1 - Left Side View of Airplane at Rest (Photo Courtesy of Beechcraft) (item 15, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417017&FileExtension=.PDF&FileName=Photo%201%20-%20Left%20Side%20View%20of%20Airplane%20at%20Rest%20(Photo%20Courtesy%20of%20Beechcraft)-Master.PDF - Photo 2 - Front View of Airplane (Photo Courtesy of Beechcraft) (item 16, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417018&FileExtension=.PDF&FileName=Photo%202%20-%20Front%20View%20of%20Airplane%20(Photo%20Courtesy%20of%20Beechcraft)-Master.PDF - Photo 3 - Right Side of Airplane (Photo Courtesy of Beechcraft) (item 17, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417019&FileExtension=.PDF&FileName=Photo%203%20-%20Right%20Side%20of%20Airplane%20(Photo%20Courtesy%20of%20Beechcraft)-Master.PDF - Photo 4 - Aft View of Airplane (Photo Courtesy of Beechcraft) (item 18, .PDF, 5.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417020&FileExtension=.PDF&FileName=Photo%204%20-%20Aft%20View%20of%20Airplane%20(Photo%20Courtesy%20of%20Beechcraft)-Master.PDF 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.