NTSB Identification: DCA89MA035.
The docket is stored on NTSB microfiche number 38043.
Nonscheduled 14 CFR
Accident occurred Saturday, March 18, 1989 in SAGINAW, TX
Probable Cause Approval Date: 06/10/1991
Aircraft: McDonnell Douglas DC-9-33F, registration: N931F
Injuries: 2 Fatal.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

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)

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

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.

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