# NTSB ERA17CA068: Beech A36, N776WM, New Smyrna Beach, FL, December 12, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: December 12, 2016, 15:30 local (20:30 UTC) - Place: New Smyrna Beach, FL - Coordinates: 29.051944, -81.035278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.0519&lon=-81.0353&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report August 22, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 94497 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17CA068 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94497/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94497 - Page: https://openairdocs.org/ntsb/ERA17CA068 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 11 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1151604), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 17 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1151604), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/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 A36, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1151604), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=1151604), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) - [Doors: emergency exit](https://openairdocs.org/ntsb-findings/01035220): Aircraft › Aircraft structures · Incorrect service/maintenance (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01035220/cases.md?model=1151604), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/01035220/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Beech A36, 7 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=1151604), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=1151604), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1151604), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern downwind: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1151604), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech A36, 31 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1151604), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [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 A36, 9 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=1151604), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## 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](https://openairdocs.org/deregistered/N776WM-2018-05-31), registration cancelled 2018-05-31, S/N E-2088, built 1983 (OpenAirDocs) - Reported make and model: BEECH A36 (UNDESIGNAT) - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550-B](https://openairdocs.org/engine/continental-io-550-b) (registry code 17208, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-2088 - Year built: 1983 - Airframe hours: 3451 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; 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 ## 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 20161212019349A](https://openairdocs.org/incident/20161212019349A), Dec 12, 2016: Beech A36, New Smyrna, FL, Destroyed. ^Mr. Kraus^ flew from conneticut to Spruce Creek, FL a week prior to the accident. During that flight the aircraft cabin was reported as being cold due to an… ## Docket (6 files) The files NTSB released with the investigation on August 3, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94497. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 922 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454793&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements and Interview Summaries (item 2, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454794&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Master.PDF - Excerpts from Beechcraft A36 POH - Doors, Windows, and Exits (item 3, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454795&FileExtension=.PDF&FileName=Excerpts%20from%20Beechcraft%20A36%20POH%20-%20Doors,%20Windows,%20and%20Exits-Master.PDF - Excerpts from Beechcraft A36 IPC - LH and RH Openable (Emergency Exit) Windows (item 4, .PDF, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454796&FileExtension=.PDF&FileName=Excerpts%20from%20Beechcraft%20A36%20IPC%20-%20LH%20and%20RH%20Openable%20(Emergency%20Exit)%20Windows-Master.PDF - Photo Array (item 5, .PDF, 838 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454797&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454798&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.