# NTSB LAX93FA287: Cessna 402C, N818AN, Las Vegas, NV, July 12, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 12, 1993, 14:40 local (21:40 UTC) - Place: Las Vegas, NV - Location: 36.0803° N, 115.1524° W: Placed by OpenAirDocs at HARRY REID INTL (LAS), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=36.0803&lon=-115.1524&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report June 22, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28337 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93FA287 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28337/pdf - Page: https://openairdocs.org/ntsb/LAX93FA287 ## Probable cause THE PILOT'S FAILURE TO MAINTAIN ADEQUATE AIRSPEED WHILE MANEUVERING IN THE TRAFFIC PATTERN. A FACTOR WHICH CONTRIBUTED TO THE ACCIDENT WAS THE PILOT'S FAILURE TO ASSURE THAT THE NOSE BAGGAGE COMPARTMENT DOOR WAS SECURED. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - door,cargo/baggage - not secured (contributing factor) - aircraft preflight - inadequate, pilot in command (contributing factor) - door,cargo/baggage - open - airspeed(vmc) - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PILOT HAD A 25 MIN TURNAROUND FOR THE ACCIDENT TRIP FROM THE PRIOR FLIGHT. NO WITNESSES WERE FOUND WHO OBSERVED THE PILOT PREPARING FOR THE FLIGHT OR PERFORMING A PREFLIGHT INSPECTION. COMPANY PROCEDURES SPECIFY THAT THE PILOTS ARE RESPONSIBLE FOR LOADING AND UNLOADING THE BAGGAGE. THE MANIFEST FOR THE PRIOR FLIGHT SHOWED 54 LBS OF BAGGAGE IN THE NOSE COMPARTMENT. SHORTLY AFTER LIFTOFF, THE PILOT TOLD THE LOCAL CONTROLLER THAT THE BAGGAGE DOOR WAS OPEN AND HE REQUESTED A 'GO AROUND.' THE LOCAL CONTROLLER TOLD THE PILOT TO MAKE RIGHT TRAFFIC. MULTIPLE WITNESSES SAW THE AIRPLANE IN A NOSE HIGH ATTITUDE DURING THE INITIAL CLIMB AFTER TAKEOFF. THEY REPORTED THE PILOT ENTERED A RIGHT TURN WHICH CONTINUED UNTIL THE AIRPLANE 'FELL TO THE GROUND AND HIT NOSE FIRST.' AN AIRLINE PILOT WITNESS SAID THAT THE AIRPLANE'S ACTIONS WERE A 'CLASSIC VMC ROLL.' OTHER WITNESSES REPORTED THAT THE LEFT NOSE BAGGAGE COMPARTMENT DOOR WAS OPEN DURING THE TAKEOFF AND INITIAL CLIMB. EVIDENCE SHOWS THAT THE RIGHT ENG WAS DEVELOPING LITTLE OR NO POWER. ## Factual narrative HISTORY OF FLIGHT: On July 12, 1993, at 1441 hours Pacific daylight time, a Cessna 402C, N818AN, collided with the terrain during an uncontrolled descent at McCarran International Airport, Las Vegas, Nevada. The airplane was destroyed during the impact sequence and the post impact fire. The certificated airline transport pilot and his two passengers received fatal injuries. The airplane was being operated as a scheduled commuter flight by Air Nevada Airlines, Incorporated, under the provisions of CFR 14 Part 135 of the Federal Aviation Regulations at the time of the accident. The airplane was departing Las Vegas and was destined for Grand Canyon, Arizona, when the accident occurred. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed. According to Air Nevada Airlines documents and witness interviews, the pilot had two days off prior to the day of the accident. Witnesses said he reported to work about 1000 hours the morning of the accident. Air Nevada Airlines company schedules show the pilot flew a flight to the Grand Canyon airport at 1135 hours. The same documents show the pilot departed Grand Canyon Airport to return to Las Vegas at 1300 hours. His arrival time at Las Vegas according to the documents was 1405 hours. The airplane flown by the pilot on the flights to and from the Grand Canyon Airport was N818AN, the accident airplane. According to the manifest, the pilot had nine passengers on the flight to and from Grand Canyon and 54 pounds in the nose baggage compartment. No one could be found who witnessed the pilot's actions when he returned from Grand Canyon Airport. According to the company's operating manual, the pilot is responsible for removing all baggage from the airplane's baggage compartments. The next flight the pilot was scheduled to fly was Air Nevada Airlines Flight number 83 from Las Vegas to Grand Canyon. According to company officials, the intended route of flight included sight seeing over the western end of the Grand Canyon while flying a route named "Blue 1" on the special visual flight rules aeronautical chart. The "Official Airline Guide" states Air Nevada Flight number 83 has a scheduled departure time from Las Vegas of 1430 hours. The pilot landed at Las Vegas at 1405 hours from the previous flight, which gave him a 25 minute turn around. No witness were found who observed the pilot preparing for Air Nevada flight number 83. According to recorded tape transcripts between the pilot and the FAA local controller at in the tower at McCarran International Airport, the pilot, with two passengers aboard the airplane, was cleared for takeoff at 1439:53 hours. At 1440:32, the pilot told the local controller the airplane's baggage door was open. During this conversation, the pilot requested a "go around." At 1440:38 hours, the local controller told the pilot to "make right traffic." According to multiple witnesses, the airplane was in a "nose high" attitude during the initial climb after takeoff. They reported the pilot entered a right turn which continued until the airplane "fell to the ground and hit nose first." The witnesses reported the airplane exploded upon contact with the ground. One witness, an airline pilot, reported that he observed the airplane from its takeoff until it crashed. He said he noticed the airplane in a "nose high climb attitude." He described the airplane's actions as a "classic vmc (minimum controllable airspeed with the critical engine inoperative) roll." Other witnesses reported that the left nose baggage compartment door was open during the takeoff and initial climb. According to taped transcripts, the FAA local controller activated the crash phone to the airport fire department at 1440:59. The fire department responded to the accident and extinguished the fire. The accident occurred at McCarran International Airport at the approximate coordinates of 36 degrees and 5 minutes north latitude and 115 degrees and 10 minutes west longitude. CREW INFORMATION: The pilot's company flight records and his FAA airman certification file were reviewed after the accident. According to those records the pilot was qualified and current for the assigned flight in accordance with applicable Federal Aviation Regulations. AIRCRAFT INFORMATION: Review of the maintenance and modification records revealed that the airplane had the left nose baggage compartment door modified to include an additional securing lock. The door had a total of four locks to secure it to the airplane. According to company officials, the additional securing lock was put on the airplane by its previous owners, a commuter airline located in the northeastern United States. Cessna Aircraft Service Bulletin number MEB87-3, dated May 22, 1987, details the installation of an additional securing lock. The lock placed on the airplane's forward nose baggage compartment did not have the securing lock detailed in this Service Bulletin. METEOROLOGICAL INFORMATION: A weather observation facility is located at McCarran International Airport. A weather observation was taken at 1446 hours. In part, that observation was: "visual meteorological conditions; clear sky; 35 statute miles visibility; temperature 100 degrees fahrenheit; dew point 36 degrees fahrenheit; wind from 190 degrees magnetic at 9 nautical miles per hour; and an altimeter setting of 29.97 inches of mercury." WRECKAGE AND IMPACT INFORMATION: The accident site is located on airport property at McCarran International Airport. The ground at the accident site is level and consists primarily of gravel with no vegetation. Two circular impressions were located to the south of the main wreckage. The impressions measured about 18 inches in diameter and were about 6 to 9 inches deep. The center of the impressions were measured at about fifteen feet and one inch from center to center. A comparison measurement was taken between the propeller spinners of an exemplar aircraft and found to be about the same as the distance between the two impressions. Portions of the airplane's radome were found to the southeast of the impressions by about 10 feet. The left propeller assembly was also found at the location. The right propeller assembly was found adjacent to the southern most impression. The main wreckage was located on a magnetic bearing of about 285 degrees at a distance of about 30 feet from the two impressions. The fuselage was upright and was oriented on a magnetic bearing of about 165 degrees. The main wreckage was located about 75 feet north of Taxiway D2 and about 75 feet west of Taxiway D. The main wreckage consisted of the airplane's fuselage, both wings, and the empennage. Both engines were separated from the airframe and were found lying behind their respective wings. The airplan ## Aircraft - Registration: [N818AN](https://openairdocs.org/deregistered/N818AN-1994-09-06), registration cancelled 1994-09-06, S/N 402C0324 (OpenAirDocs) - Reported make and model: CESSNA 402C - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Category: Airplane - Serial number: 402C-0324 - Airframe hours: 11513 - Engines: CONTINENTAL TSIO-520-UB 325 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Air Nevada Airlines - Registered owner: Abbey Mere, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, June 24, 1993, 52 hours before - Departed: LAS - Destination: GCN, GRAND CANYON, AZ - Flight plan: VFR - Airport: LAS, Mccarren International, runway 19L, 9,776 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; flight instructor, airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 4,120 total, 568 in this make and model, 3,968 as pilot in command, 198 in the last 90 days, 60 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 35 statute miles - Lowest ceiling: none - Temperature: 100 °F, dew point 36 °F - Altimeter: 29.00 inHg - Observed at: LAS, 1 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 19930712023139A](https://openairdocs.org/incident/19930712023139A), Jul 12, 1993: Cessna 402CESSNA, Las Vegas, NV, Destroyed, 3 fatal. Cargo door open on climbout. Began nose high right turn to return. Lost right engine. Below VMC. Rolled. Dived in. 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.