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NTSB Report
June 28, 1991 · Beech B19 · N18989
Addison, TX
Overview
Report Status
Probable Cause
Event Type
Accident
Date
June 28, 1991
Injury Outcomes
1 injury (1 minor injury)
Location
Addison, TX
Aircraft
Beech B19
Tail Number
N18989
Operator
Ari Ben Aviator
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
FTW91LA110
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.
NTSB 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.
Full Narrative
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.
Flight
Event TypeAccident
Event Time16:30 CDT
Nearest AirportADDISON (0nm N)
Runway0
Runway Length0
Runway Width0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftBeech B19
Tail NumberN18989
Aircraft CategoryAir
DamageSubstantial
OperatorAri Ben Aviator
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · O-320-E3D · Reciprocating · 150
Seats4
People & Injuries
Injury Summary1 injury (1 minor injury)
Fatal0
Serious0
Minor1
Uninjured0
Total1
Crew 1Age 24 · Third Class
Conditions
ConditionsVMC
LightDaylight
WindCalm
Visibility10 sm
CeilingNone
Temperature / Dew Point0 C
Altimeter0
Weather SourcePILO