GAA16CA060

NTSB accident investigation · Beech 56 · Hudson, CO · November 22, 2015

Accident · No injuriesData collectionFinal report
Date
November 22, 2015, 16:30 local (23:30 UTC)
Place
Hudson, CO
Injuries
6 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N12WBBeech 56
Defining event
Landing: Loss of control in flight
Weather
Visual (VMC) · Dusk
Status
Completed · report March 14, 2016
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20151122018699A
Case key
92369

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

On this page

Probable cause

The pilot's failure to maintain directional control during the landing. Contributing to the accident was the distraction of the open cabin door.

Findings · 5

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.

Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedBeech 56TC: 1 caseAll aircraft: 3,958 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBeech 56TC: 1 caseAll aircraft: 9,295 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · MalfunctionBeech 56TC: 1 caseAll aircraft: 86 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · Incorrect service/maintenanceBeech 56TC: 1 caseAll aircraft: 86 cases
Attention/monitoring: attentionPersonnel issues › Psychological · PilotBeech 56TC: 1 caseAll aircraft: 226 casesProbable cause

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

The pilot reported that prior to the takeoff roll, his son, who was positioned in the front right seat, had difficulty shutting and locking the cabin door. The pilot reported that he reached over and ensured the door was locked. The pilot reported that shortly after liftoff the cabin door came open. He maneuvered the airplane to stay in the traffic pattern and return to land. He reported that while on final he did not have any rudder authority and was unable to keep directional control. The pilot reported that prior to the initial impact he lost sight of the runway when the airplane pitched up and rolled left simultaneously. Subsequently the left wing impacted the ground and sustained substantial damage.

Factual narrative

The pilot reported that prior to the takeoff roll, his son, who was positioned in the front right seat, had difficulty shutting and locking the cabin door. The pilot reported that he reached over and ensured the door was locked. The pilot reported that shortly after liftoff the cabin door came open. He maneuvered the airplane to stay in the traffic pattern and return to land. He reported that while on final he did not have any rudder authority and was unable to keep directional control. The pilot reported that prior to the initial impact he lost sight of the runway when the airplane pitched up and rolled left simultaneously. Subsequently the left wing impacted the ground and sustained substantial damage. The cabin door is hinged in the front and secured at the top, bottom, and aft edge when closed and locked. A post-accident examination of the door by the National Transportation Safety Board investigator-in-charge revealed that the lower striker plate, which secures the bottom of the door to the doorframe, had screw holes that were elongated inward about 1/8 of an inch from their original position, resulting in a misalignment. The two screws that attach the striker plate to the airframe were in place, and the striker plate was secure. The striker plate on the bottom of the cabin door frame acts as a guide for the latch pin to secure the cabin door to the airframe when in the closed and locked position. The upper and aft locking points were examined and no deficiencies were found. According to the manufacture, if the latch pin cannot extend though the striker plate, the door will be difficult to latch, and the unresolved displacement of the lower latch pin can cause feedback in the door latching system that may result in the entire latching system unlatching. According to the manufacture, a mandatory service bulletin (No. 2457, Rev. 1) was issued September, 1993 and revised February 1994. The service bulletin was issued to "provide cabin door third latch pin over-center mechanism kits that will reduce the possibility of a cabin door opening in flight." The accident airplane was not in compliance with the service bulletin. The following procedure that is listed in the airplane's Owner's Manual should be used for an unlatched door in flight. "If the cabin door is not locked it may come unlatched in flight. This usually occurs during or just after takeoff. The door will trail in a position 3 to 4 inches open, but the flight characteristics of the airplane will not be affected. Return to the field in a normal manner".

Aircraft

Registration
N12WB
Reported as
Beech 56 (TC)
Category
Airplane
Serial number
TG-82
Built
1969
Airframe hours
4,177.9
Engines
Lycoming TIO-541-E1B4, 380 horsepower, reciprocatingLycoming TIO-541-E1B4, 380 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 19, 2015
Departed
18V · Hudson, CO
Destination
DSM · Des Moines, IA
Flight plan
VFR
Airport
18V · Platte Valley Airpark, runway 15, 4,100 × 40 ft, asphalt
Equipment
Onboard weather, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Handheld GPS

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
45
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
January 2, 2014
Seat
Left
Restraint
Lap only
Flight hours
250.5 total · 44.5 in this make and model · 171.5 as pilot in command · 16 in the last 90 days · 7 in the last 30 days · 4.4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
Calm
Visibility
10 statute miles
Temperature
52 °F, dew point 18 °F
Altimeter
30.06 inHg
Observed at
KDEN, 16 nm away

Docket · 4

The files NTSB released with the investigation on March 8, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.6 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.

Other investigations on N12WB · 1

Matched to the same aircraft by N-number and date.