# NTSB GAA16CA060: Beech 56, N12WB, Hudson, CO, November 22, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: November 22, 2015, 16:30 local (23:30 UTC) - Place: Hudson, CO - Coordinates: 40.104167, -104.701942 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1042&lon=-104.7019&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed, report March 14, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 92369 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA060 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92369/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92369 - Page: https://openairdocs.org/ntsb/GAA16CA060 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1152736), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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 56TC, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1152736), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Malfunction (probable cause); cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-findings/01035210/cases.md?model=1152736), [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01035210/cases.md) - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Incorrect service/maintenance; cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-findings/01035210/cases.md?model=1152736), [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 56TC, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=1152736), [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. - [Prior to flight: Aircraft servicing event](https://openairdocs.org/ntsb-events/020); cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-events/020/sequence.md?model=1152736), [All aircraft, 70 cases](https://openairdocs.org/ntsb-events/020/sequence.md) - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=1152736), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=1152736), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 56TC, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=1152736), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N12WB-2019-01-30), registration cancelled 2019-01-30, S/N TG-82, built 1969 (OpenAirDocs) - Reported make and model: BEECH 56 (TC) - Registry model: [Beech 56TC](https://openairdocs.org/model/beech-56tc) (registry code 1152736) (OpenAirDocs) - Registry engine: [Lycoming TI0-541 series](https://openairdocs.org/engine/lycoming-ti0-541-series) (registry code 41536, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TG-82 - Year built: 1969 - Airframe hours: 4177.9 - Engines: LYCOMING TIO-541-E1B4 380 horsepower reciprocating; LYCOMING 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; 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 ## 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 20151122018699A](https://openairdocs.org/incident/20151122018699A), Nov 22, 2015: Beech 56TC, Hudson, CO, Destroyed. On Sunday 11-22-2015, aircraft N12WB, Beech barron (BE-56TC) serial number TG82, took off from platt valley airpark 18V, runway 15 with 6 people on board. At… ## Other investigations on N12WB (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 NYC83LA046](https://openairdocs.org/ntsb/NYC83LA046), Dec 21, 1982: Beech 56TC (N12WB), Gasport, NY, substantial damage ## Docket (4 files) The files NTSB released with the investigation on March 8, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92369. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 881 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437405&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Mandatory Service Bulletin 2457 (item 2, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437406&FileExtension=.PDF&FileName=Mandatory%20Service%20Bulletin%202457-Master.PDF - Unlatched Door Emergency Procedure Extract from OM 96-590008-3 (item 3, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437407&FileExtension=.PDF&FileName=Unlatched%20Door%20Emergency%20Procedure%20Extract%20from%20OM%2096-590008-3-Master.PDF - Accident Photos (item 4, .PDF, 2 photos, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437408&FileExtension=.PDF&FileName=Accident%20Photos-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.