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March 18, 1989 · Mcdonnell Douglas DC-9-33F · N931F

Saginaw, TX

Overview

Report Status
Probable Cause
Event Type
Accident
Date
March 18, 1989
Injury Outcomes
2 injuries (2 fatalities)
Location
Saginaw, TX
Aircraft
Mcdonnell Douglas DC-9-33F
Tail Number
N931F
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
DCA89MA035

As the acft rotated for tkof, the cargo door (CD) opened. The crew contd tkof & turned to a dwnwnd leg to lnd on rwy 17. They answered twr instrns to rprt 'base.' This was the last tmtn they rcvd, tho they tried svrl times to ctc twr or apch ctl. As the acft turned on base leg (with a tail wnd at tfc pattern alt), radar data indcd acft would cross the rwycenterline. Radar ctc was then lost; the acft crashed in a steep dscnt. There was evidence that bfr flt, the 1st officer misinterpreted the external lockpin manual ctl handle psn to mean the CD was locked (as a result of incorrect markings). Also, there was a malfunction of a CD open warning lgt sw, preventing opn of the warning lgt. Additionally, svrl svc bulletins (SB's) concerning the CD had not been complied with. These SB's would have provided an extra safety feature of the CD warning lgt sys, a door venting sys & a lockpin viewing window for the door. There was no emerg proc or specific guidance to aid DC-9 crews for this situation, though svrl CD openings had occurred. (See: NTSB/AAR-90/02)

NTSB Probable Cause

THE LOSS OF CONTROL OF THE AIRPLANE FOR UNDETERMINED REASONS FOLLOWING THE INFLIGHT OPENING OF THE IMPROPERLY LATCHED CARGO DOOR. CONTRIBUTING TO THE ACCIDENT WERE: INADEQUATE PROCEDURES USED BY EVERGREEN AIRLINES AND APPROVED BY THE FAA FOR PREFLIGHT VERIFICATION OF CARGO DOOR SECURITY, EVERGREEN'S FAILURE TO MARK PROPERLY THE AIRPLANE'S EXTERNAL CARGO DOOR LOCKPIN MANUAL CONTROL HANDLE, AND THE FAILURE OF MCDONNELL DOUGLAS TO PROVIDE FLIGHTCREW GUIDANCE AND EMERGENCY PROCEDURES FOR AN INFLIGHT OPENING OF THE CARGO DOOR. ALSO CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF THE FAA TO MANDATE MODIFICATION TO THE DOOR-OPEN WARNING SYSTEM FOR DC-9 CARGO-CONFIGURED AIRPLANES, GIVEN THE PREVIOUS KNOWN OCCURRENCES OF INFLIGHT DOOR OPENINGS.

Full Narrative

AS THE ACFT ROTATED FOR TKOF, THE CARGO DOOR (CD) OPENED. THE CREW CONTD TKOF & TURNED TO A DWNWND LEG TO LND ON RWY 17.THEY ANSWERED TWR INSTRNS TO RPRT 'BASE.' THIS WAS THE LAST TMTN THEY RCVD, THO THEY TRIED SVRL TIMES TO CTC TWR OR APCH CTL. AS THE ACFT TURNED ON BASE LEG (WITH A TAIL WND AT TFC PATTERN ALT), RADAR DATA INDCD ACFT WOULD CROSS THE RWYCENTERLINE. RADAR CTC WAS THEN LOST; THE ACFT CRASHED IN A STEEP DSCNT. THERE WAS EVIDENCE THAT BFR FLT, THE 1ST OFFICERMISINTERPRETED THE EXTERNAL LOCKPIN MANUAL CTL HANDLE PSN TO MEAN THE CD WAS LOCKED (AS A RESULT OF INCORRECT MARKINGS).ALSO, THERE WAS A MALFUNCTION OF A CD OPEN WARNING LGT SW, PREVENTING OPN OF THE WARNING LGT. ADDITIONALLY, SVRL SVC BULLETINS (SB'S) CONCERNING THE CD HAD NOT BEEN COMPLIED WITH. THESE SB'S WOULD HAVE PROVIDED AN EXTRA SAFETY FEATURE OF THE CD WARNING LGT SYS, A DOOR VENTING SYS & A LOCKPIN VIEWING WINDOW FOR THE DOOR. THERE WAS NO EMERG PROC OR SPECIFIC GUIDANCE TO AID DC-9 CREWS FOR THIS SITUATION, THOUGH SVRL CD OPENINGS HAD OCCURRED. (SEE: NTSB/AAR-90/02)

Flight

Event TypeAccident
Event Time02:16 CST
Nearest AirportCarswell Afb (0nm N)
Runway17
Runway Length12000 ft
Runway Width300 ft
Flight Plan FiledIFR
Aircraft FireGrd
Aircraft ExplosionNo

Aircraft

AircraftMcdonnell Douglas DC-9-33F
Tail NumberN931F
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsP&W · JT8D-9A · Turbofan · 14500
Seats3

People & Injuries

Injury Summary2 injuries (2 fatalities)
Fatal2
Serious0
Minor0
Uninjured0
Total2
Crew 1Age 42 · First Class

Conditions

ConditionsVMC
LightDark Night
Wind320° @ 6 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point66 F / 0 C
Altimeter30.00 inHg
Observation Time08:21
Weather SourceWFAC

Appendix: Source Data