ERA17CA068

NTSB accident investigation · Beech A36 · New Smyrna Beach, FL · December 12, 2016

Accident · Minor injuriesData collectionFinal report
Date
December 12, 2016, 15:30 local (20:30 UTC)
Place
New Smyrna Beach, FL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N776WMBeech A36
Defining event
Approach-VFR pattern downwind: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 22, 2017
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20161212019349A
Case key
94497

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inappropriate response to an emergency exit window opening in flight, which resulted in a loss of control, precautionary off-airport landing, and subsequent impact with trees. Contributing to the accident was the pilot's improper repair of the emergency exit window before the flight.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · PilotBeech A36: 11 casesAll aircraft: 1,386 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBeech A36: 17 casesAll aircraft: 1,391 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech A36: 43 casesAll aircraft: 9,295 casesProbable cause
Maintenance: repairPersonnel issues › Task performance · PilotBeech A36: 2 casesAll aircraft: 99 casesProbable cause
Doors: emergency exitAircraft › Aircraft structures · Incorrect service/maintenanceBeech A36: 1 caseAll aircraft: 1 caseProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech A36: 7 casesAll aircraft: 1,310 cases
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeBeech A36: 6 casesAll aircraft: 933 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Passengers reported that, during a winter flight, cold air was entering the airplane from the left side of the passenger cabin. Afterward, the pilot examined the area and discovered that there was a small gap under the emergency exit window that was allowing air to enter the cabin from outside the airplane. He opened the window and examined the rubber seal, which was intact. However, he could not tell if it was compressed or thinner than normal. He then closed and latched the window and inspected the latch with a flashlight to make sure it was latched. Because he was going to fly back to his home airport in similar winter conditions on the next flight, he took several rolled-up paper towels and placed them between the trim and the window to try and keep the cold air out and placed a strip of blue painter's tape on the outside of the lower portion of the window to further reduce the entry of cold air. He decided to fly the airplane once around the traffic pattern before fueling up for his return flight. After takeoff and while on the downwind leg of the traffic pattern at 800 ft, he suddenly heard a "whoosh" behind his seat. Instead of landing and checking to see what happened, he checked for other traffic, turned on the autopilot, in heading and altitude mode, then reached around behind him to shut and latch the window, which had opened 2 to 3 inches. Seconds later, after turning back around to his normal seated position, he heard a loud "pop" and turned around and saw that the window had opened completely. Given that he was afraid it would come off the airplane and strike the tail, he reached back again and pulled the window down. The pilot reported that he must have "bumped" the autopilot off while he was doing this, because when he looked forward to check for traffic, he noticed that the airplane was approaching the ground. He then banked left and right to determine his location and spot any obstacles, raised the nose, and added power to climb. He then noticed that there were power lines slightly higher than his altitude directly in front of him, and rather than risk a possible stall close to the ground by pulling back suddenly, he lowered the nose and "put" the airplane on the ground. The airplane then struck trees, and a fire ensued, which resulted in substantial damage to the airframe. Examination of the emergency exit window by a Federal Aviation Administration inspector revealed that the paper towels the pilot inserted in the gap between the window and the airframe were interfering with the window's latching mechanism.

Factual narrative

During a winter flight, passengers reported that cold air was entering the airplane from the left side of the passenger cabin. Afterwards, the pilot examined the area and discovered that there was a small gap under the emergency exit window that was allowing air to enter the cabin from outside the airplane. He opened the window and examined the rubber seal which was intact. He could not tell though, if it was compressed or thinner than normal. He then closed and latched the window and inspected the latch with a flashlight to make sure it was latched. Since he was going to fly back to his home airport in similar winter conditions on the next flight, He took several rolled-up paper towels and placed them between the trim and the window to try and keep the cold air out, and placed a strip of blue painters tape on the outside of the lower portion of the window to further reduce the entry of cold air. Since it was a beautiful day, he decided to fly the airplane once around the traffic pattern before fueling up for his return flight. After takeoff while on the downwind leg of the traffic pattern at 800 feet, he suddenly heard a "whoosh" behind his seat. Instead of landing, and then checking to see what happened, he instead checked for other traffic, turned on the autopilot, in heading and altitude mode, then reached around behind him to shut and latch the window which had opened 2 to 3 inches. Moments later, after turning back around to his normal seated position, he then heard a loud "pop" and turned around to find that the window had now opened completely. Since he was afraid it would come off the airplane and strike the tail, he reached back once again and pulled the window back down. The pilot advised that he must have "bumped" the autopilot off while he was doing this, since when he looked forward to check for traffic, he noticed that the airplane was approaching the ground. He then banked left and right to determine his location and spot any obstacles, raised the nose, and added power to climb. He then noticed that there were powerlines slightly higher than his altitude directly in front of him, and rather than risk a possible stall close to the ground by pulling back suddenly, he lowered the nose and "put" the airplane on the ground. At this point the airplane was approaching the edge of a field bordered by trees, so he pointed the nose of the airplane between trees. The airplane then struck the trees, and a fire ensued, resulting in substantial damage to the airframe. Examination of the emergency exit window by a Federal Aviation Administration inspector revealed that the paper towels the pilot inserted in the gap between the window and the airframe were interfering with the window's latching mechanism.

Aircraft

Registration
N776WM
Reported as
Beech A36 (UNDESIGNAT)
Category
Airplane
Serial number
E-2088
Built
1983
Airframe hours
3,451
Engine
Continental IO-550-B, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · February 17, 2016 · 130 hours before
Departed
7FL6 · New Smyrna Beach, FL
Destination
7FL6 · New Smyrna Beach, FL
Airport
7FL6 · Spruce Creek
Equipment
Auto-pilot, Onboard weather, Stall warning system

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
61
Injuries
Minor
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 4, 2016
Seat
Left
Restraint
3-point
Flight hours
15,881 total · 173 in this make and model · 13,000 as pilot in command · 116 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 66 °F
Altimeter
30.05 inHg
Observed at
EVB, 5 nm away

Docket · 6

The files NTSB released with the investigation on August 3, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.5 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.