# NTSB FTW91LA110: Beech B19, N18989, Addison, TX, June 28, 1991

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: June 28, 1991, 16:30 local (21:30 UTC)
- Place: Addison, TX
- Coordinates: 32.959228, -96.829704 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.9592&lon=-96.8297&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 1 minor
- Status: Completed, report March 24, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 23355
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW91LA110
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/23355/pdf
- Page: https://openairdocs.org/ntsb/FTW91LA110

## Probable cause

ENTRY DOOR OPENING IN FLIGHT, INADEQUATE EMERGENCY PROCEDURES PUBLISHED BY THE MANUFACTURER, AND POOR EMERGENCY TRAINING BY THE STUDENT'S INSTRUCTOR. FACTORS WERE INADEQUATE DESIGN/INSTALLATION OF THE DOOR LOCKING MECHANISM, DETERIORATED AIRPLANE PERFORMANCE, AND THE PILOT'S FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE.

## Sequence of events

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

- Miscellaneous/other, takeoff - initial climb
  - door - open (cause)
  - emergency procedure - inadequate, manufacturer (cause)
  - inadequate training(emergency procedure(s)), flight instructor(on ground) (cause)
  - maintenance,installation - inadequate, manufacturer (contributing factor)
  - aircraft performance - deteriorated (contributing factor)
- Loss of control - in flight, approach - vfr pattern - base turn
  - stall - inadvertent, pilot in command (cause)
- In flight collision with terrain/water, descent - uncontrolled
  - object - tree(s)
  - terrain condition - residential area

## Analysis

THE STUDENT PILOT'S DOOR OPENED IMMEDIATELY AFTER TAKEOFF. THE TAKEOFF WAS CONTINUED WITH REPEATED ATTEMPTS MADE TO CLOSE THE DOOR. THE AIR TRAFFIC CONTROL TOWER WAS ADVISED OF THE SITUATION BUT AN EMERGENCY WAS NOT DECLARED. WHILE ON AN EXTENDED FINAL APPROACH, WHICH RESULTED FROM ATCT INSTRUCTIONS, CONTROL OF THE AIRPLANE WAS LOST DUE TO THE OPEN DOOR. THE AIRPLANE COLLIDED WITH TREES AND CAME TO REST IN A RESIDENTIAL AREA. THE INSTRUCTOR HAD NEVER DEMONSTRATED A DOOR OPEN SITUATION IN FLIGHT. BEECHCRAFT HAD ISSUED SPECIFIC PROCEDURES FOR THIS EMERGENCY IN MARCH, 1987, VIA A SAFETY COMMUNIQUE. THESE PROCEDURES WERE NEVER INCORPORATED INTO THE PILOT'S OPERATING HANDBOOK. THE FAA OPERATIONS INSPECTOR, THE OPERATOR, THE FLIGHT INSTRUCTOR AND THE STUDENT PILOT HAD NO KNOWLEDGE OF THE SAFETY COMMUNIQUE PROCEDURES.

## Aircraft

- Registration: [N18989](https://openairdocs.org/deregistered/N18989-1994-01-27), registration cancelled 1994-01-27, S/N MB870 (OpenAirDocs)
- Reported make and model: Beech B19
- Registry model: [Beech B19](https://openairdocs.org/model/beech-b19) (registry code 1151215) (OpenAirDocs)
- Category: Airplane
- Serial number: MB-870
- Engines: LYCOMING O-320-E3D 150 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Ari Ben Aviator
- Registered owner: Ari Ben Aviator
- Airworthiness certificate: Standard, Normal
- Airport: ADS, Addison

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 24; student; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 42 total, 42 in this make and model, 8 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 99 °F, dew point -0 °F

## 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 19910628024899A](https://openairdocs.org/incident/19910628024899A), Jun 28, 1991: Beech B19, Dallas, TX, Substantial damage. Door came open on climbout. Unable to close. Circling to landing flew into ground.

## Other investigations on N18989 (1)

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.

- [NTSB FTW90LA132](https://openairdocs.org/ntsb/FTW90LA132), Jul 3, 1990: Beech B19 (N18989), Mc Kinney, TX, substantial damage. Probable cause: INADEQUATE SUPERVISION BY THE PIC, THE INSTRUCTOR PILOT, WHEN HE ALLOWED THE STUDENT PILOT TO FLARE AT TOO HIGH AN ALTITUDE OFF THE RUNWAY.

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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