DFW06FA180
DFW06FA180

HISTORY OF FLIGHT

On July 11, 2006, at 1132 eastern daylight time, a single-engine Beech C24R airplane, N78MB, sustained substantial damage when it collided with trees and terrain following a loss of control while attempting to return to land on Runway 32 at the Norfolk International Airport (ORF), near Norfolk, Virginia. The instrument rated private pilot, his passenger, and two dogs sustained fatal injuries. The airplane was registered to, and operated by the pilot. An instrument flight rules (IFR) flight plan was filed for the cross-country flight destined for the Hilton Head Island Airport (HXD), near Hilton Head, South Carolina. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91.

A review of the air traffic control communications revealed the flight was cleared for take-off on Runway 32 (a 4,875-foot-long, by 150-foot-wide asphalt runway) at 1127:04. Less than a minute later, the pilot contacted the control tower and stated "need to come around and land again...I got a door open." A tower controller then instructed the pilot to turn left and enter the downwind leg of the traffic pattern for Runway 32, and the pilot acknowledged. The controller then asked the pilot if he was able to make a short approach, to which the pilot replied that he could. The controller then cleared the pilot to land on Runway 32. A few moments later, the tower controller advised the pilot to extend the downwind leg due to traffic on final approach, and that the tower would inform him when he could turn onto the base leg. The pilot again acknowledged the radio transmission. At 1129:43, the tower controller instructed the pilot to turn onto the base leg, and again, the pilot acknowledged. This was the last radio communication received from the pilot.

A review of the radar data indicated the airplane departed runway 32 and leveled-off at an altitude of 200 feet mean sea level (msl), while maintaining a ground speed of 100 knots. Radar data revealed that the airplane executed a left turn to a southeasterly heading and flew parallel to the runway. Radar data also revealed that as the airplane proceeded on this heading, its ground speed decreased to 70 knots. When the airplane was about one-mile beyond the end of the runway, another left turn was initiated toward the northeast before the radar data ended at 1130.

A witness, who was working in his garage, reported that he heard "a large shaking sound which sounded like a semi-type truck braking down in front of [his] house." The witness then looked up and saw the airplane flying "very slow" about 20-feet-high above the tree line. The airplane was shaking and it sounded like it was losing power. The witness was provided a model airplane to demonstrate the flight attitude of the airplane. The witness demonstrated that the airplane had a slightly nose-high attitude and was in a shallow left hand turn. The airplane was shaking violently. The witness then maneuvered the model airplane so it simultaneously rolled rapidly to the left (inverted) and the nose of the airplane dropped toward the ground. The witness further stated that he lost sight of the airplane as it descended into the trees.

PILOT INFORMATION

The pilot held a private pilot certificate for airplane single engine land, with an instrument rating. His last Federal Aviation Administration (FAA) third class medical was issued on January 27, 2005. At that time the pilot reported he had accumulated a total of 1,300 flight hours. A review of the pilot's logbook revealed that his last entry was made on June 10, 2006. At that time he had logged a total of 1,493.3 hours.

METEOROLOGICAL CONDITIONS

Weather reported at the Norfolk International Airport at 1151 was wind from 230 degrees at 9 knots, 10 miles visibility, clear skies, 89 degrees Fahrenheit, 66 degrees Fahrenheit, and a barometric pressure setting of 30.11 inches of Mercury.

WRECKAGE INFORMATION

The airplane came to rest in the inverted position in the backyard of a private residence on a heading of 185 degrees, at an elevation of approximately 26 feet msl. The accident occurred during the hours of daylight approximately 36 degrees, 52 minutes, north latitude, and 076 degrees, 10 minutes west longitude.

The initial impact point was a stand of approximately 70-foot-high trees. From the point of initial impact to where the main wreckage came to rest was approximately 116 feet. Examination of the trees found along the wreckage path revealed numerous impact marks that got progressively lower in the direction of the main wreckage on an approximate angle of 42 degrees. The area around the wreckage was permeated with the odor of aviation gasoline.

Found along the wreckage path were the left wing, the landing light, the left main wheel, the rudder, stabilator, the right aileron, and the right wing tip. Also found along the wreckage path were numerous downed trees limbs. Some of the branches exhibited angular cuts with black paint transfer marks.

The main wreckage consisted of the right wing, propeller, engine, cockpit, fuselage, empennage, and the vertical stabilizer.

The leading edges of both wings and the stabilator exhibited impact damage. Flight control continuity was established for all primary flight control surfaces.

Examination of the flap actuator revealed the flaps were fully retracted. The landing gear was also found in the retracted position. The elevator trim actuator exhibited impact damage and a measurement could be obtained.

The left main cabin door remained attached to the fuselage; was unlatched and exhibited impact damage. Due to this damage, the door's internal and external handles could not be functionally tested; however, the latching mechanisms were intact and undamaged. The right main cabin door also remained attached to the fuselage; was unlatched, and exhibited some impact damage. Both the internal and external handles were tested and they functioned normally and the latching mechanisms were intact and undamaged. The cargo door (aft left side of fuselage) was also found open and exhibited impact damage. The section of empennage that surrounded the door also exhibited impact damage. The external handle was locked from the outside, but the internal handle functioned normally when the locking pin was pulled. Examination of the latching mechanisms revealed they were intact and undamaged.

The engine remained attached to the airframe. The engine was manually rotated via the propeller flange, and valve train continuity and compression was established on each cylinder. The spark plugs were removed and appeared normal. Both magnetos were removed, and the ignition leads were cut at the terminals. Spark was produced to all leads when manually rotated. The fuel nozzles were removed and were absent of debris. Fuel was present in the engine driven fuel pump, fuel injector servo, and the fuel manifold. Fuel injector servo inlet screen was absent of debris. Oil was present in the engine. The oil filter was removed and the element was absent of debris. The oil suction screen was also absent of debris. The propeller governor was removed and the oil screen was absent of debris.

The two-bladed propeller remained attached to the engine. Both blades were twisted and exhibited s-bending; however, only one blade was loose in the hub.

AIRCRAFT INFORMATION

The airplane, serial number MC-645, was a four-seat, single-engine, low-wing airplane. Its last annual inspection was completed on August 22, 2005, at a total airframe time of 4,834.77 hours.

Prior to departure, the pilot purchased 12.9 gallons of 100 LL aviation fuel, which topped both fuel tanks for a total of 60 gallons.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted on the pilot on July 12, 2006, by the Virginia Medical Examiner's office, Norfolk, Virginia. The pilot's cause of death was determined to be multiple impact injuries.

Toxicological testing was conducted by the FAA's Toxicological Laboratory, in Oklahoma City, Oklahoma.

ADDITIONAL INFORMATION

An estimated weight and balance was prepared using the airplane's weight and balance information found in the Airplane Flight Manual (AFM). Based on information provided by the medical examiner, animal control personnel, fuel loading, and actual weights of luggage (weighed using a bathroom scale at the accident site), the airplane was estimated to be approximately two pounds over its maximum gross weight of 2,750 pounds. The airplane's center of gravity was within limitations.

According to the AFM, which was found in the airplane, the stall speed of the airplane with flaps retracted, at maximum gross weight, in straight and level flight was 66 knots. The stall speed increased as bank angle increased.

On August 21, 1990, Beechcraft Aircraft Corporation issued a Service Communique as a "reminder of what action should be taken if a cabin door is improperly latched or becomes unlatched prior to or during flight. The Communique was issued due to accidents that had occurred after cabin doors had opened because the pilot did not properly latch them prior to takeoff. It stated:

"Properly latching and checking the doors is the pilot's responsibility. All pilots must do the following with regard to the cabin doors:

1. Follow the Before Takeoff Checklist. Make certain that the doors are properly latched before takeoff. Close the door by pulling it firmly using the armrest. Then check the door by pressing firmly outward on the aft edge of the top and bottom of the door. Make certain the door was firmly latched at both latches. If any movement is noted, open the door and close it again in accordance with the above procedure.

2. If a door is not properly latched it may come open during takeoff or in flight. Do not attempt to immediately close the door. Additional noise is expected when the door is open. Loose items may be drawn out of the cabin. The door will trail open approximately three inches which will increase drag. Do not permit yourself to be distracted by the open door. ALWAYS MAINTAIN CONTROL OF THE AIRPLANE.

3. Tests conducted with an open door in flight confirm that the airplane flight characteristics are not changed. However:

- Climb performance is decreased substantially due to the airplane flight characteristics of the open door.

- On the airplanes tested, the greater reduction in climb performance was about a 130 fpm reduction from the handbook value.
- Remember that climb performance decreases with density altitude. Consequently, at higher density altitudes the resulting percentage reduction in climb performance with the additional drag of an open door is more significant.

- Service ceiling is reduced.

- Airspeed and altimeter indications may be affected at slow airspeeds approaching stall speed.

- The altered pressure field sensed by the static system due to the open door will cause the airspeed indicator to read higher than actual airspeed near stall. However, airspeed indication is accurate (within 1 knot) at normal approach speeds and above.

- Maximum altitude is lost in a stall may increase.

4. If a door comes open, abort the takeoff if runway distance and other conditions permit. If the takeoff cannot be safely aborted or the door comes open in flight, FLY THE AIRPLANE FIRST. Continue to climb out, straight ahead if practicable, to at least pattern altitude and accelerate to and maintain normal pattern airspeed.

5. Once the airplane is stabilized in level flight with sufficient altitude and clear of traffic, the pilot can attempt to close the door as follows:

a. Maintain control of the airplane.

b. Open the pilot's storm window vent. This permits air pressure in the cabin to equalize when the door is closed.

c. Close the door by pulling it firmly using the armrest.

6. If the door cannot be closed, return to the field and land as conditions permit. MAINTAIN AT LEAST THE APPROACH AND LANDING SPEEDS RECOMMENDED IN THE PILOT'S OPERATING HANDBOOK to provide an adequate margin above stall speed. Make shallow turns not exceeding 30 degrees of bank, remember that additional power will be required to compensate for the increased drag. After landing and coming to a complete stop, close the door. Check the door as noted in Step 1 above.

In September 1990, Beechcraft released a Mandatory Service Bulletin, No. 2357, titled DOORS-CABIN DOOR LATCHING WARNING PLACARD. The bulletin was issued due to the fact that there had been reports of cabin doors opening because the pilot did not make sure the door was properly latched prior to takeoff.

The bulletin recommended that a placard (p/n: 36-530166-3) was to be affixed to the lower forward quadrant, inside of each forward cabin door window in full view of the pilot. Once an individual complied with the Service Bulletin, they were instructed to make an appropriate entry in the maintenance logbooks.

A review of the accident airplane's maintenance logbook revealed that the Service Bulletin was initially complied with during an annual inspection on April 8, 1991. On December 14, 1995, both the left and right cabin windows were removed and replaced; however, there was no entry in the logbook regarding the replacement of the Cabin Door Latching Warning placard. And, on June 13, 2003, the right cabin window was removed and replaced; however, there was no entry that the placard had been installed.

Examination of both the left and right cabin windows at the accident site revealed that the Cabin Door Latching Warning placard was not installed on either window as directed in the Mandatory Service Bulletin.

The airplane wreckage was released to a representative of the owner's insurance company on July 13, 2006.

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