NTSB Identification: FTW91LA110.
The docket is stored on NTSB microfiche number 43311.
Accident occurred Friday, June 28, 1991 in ADDISON, TX
Probable Cause Approval Date: 03/24/1993
Aircraft: Beech B19, registration: N18989
Injuries: 1 Minor.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

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.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

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.

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