Individually Owned: 150,657
Corporate Owned: 137,281
Addison Airport
Aircraft Accident/Incident Report
Addison, Texas 75001
Friday, June 28, 1991 16:30 CDT
NTSB Narrative Summary Released at Completion of Accident
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 Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 6/28/1991 |
| Event Day of the Week | Friday |
| Time of Event | 1630 |
| Event Time Zone | Central Daylight Time |
| Event City | ADDISON |
| Event State | TEXAS |
| Event Country | -- |
| Zipcode of the event site | 75001 |
| Event Date Year | 1991 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | ADDISON |
| Event Location Nearest Airport ID | ADS |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | 0 |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Pilot |
| Time of the weather observation | 0 |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | |
| Elevation of weather observation facility | 0 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 1000 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 37 |
| Dew Point at event time (in degress fahrenheit) | -18 |
| Wind Direction (degrees magnetic) | 0 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 0 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | 0 |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Minor |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | 1 |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 228 |
| NTSB Notification Source | -- |
| NTSB Notification Date | -- |
| NTSB Notification Time | 0 |
| Fiche Number and/or location -used to find docket information | 43311 |
| Date of most recent change to record | Dec 18 2002 11:28AM |
| User who most recently changed record | NTSB\GIUV |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N18989 |
| NTSB Number | FTW91LA110 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Beech |
| Aircraft Model | B19 |
| Aircraft Series Identifier | B19 |
| Aircraft Serial Number | MB-870 |
| Certified Max Gross Weight | 2250 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | Unknown |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | 0 |
| Airframe Hours | -- |
| ELT Installed | Yes |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | ARI BEN AVIATOR |
| Aircraft Owner Street Address | P. O. BOX 79 |
| Aircraft Owner City | ADDISON |
| Aircraft Owner State | TX |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 75001 |
| Operator is an individual? | -- |
| Operator Name | ARI BEN AVIATOR |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | P. O. BOX 79 |
| Operator City | ADDISON |
| Operator State | TX |
| Operator Country | |
| Operator Zip code | 75001 |
| Operator Code | |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Instructional |
| Second Pilot on Board | No |
| Departure Point Same as Event | Yes |
| Departure Airport Code | |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 1625 |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | |
| Destination City | |
| Destination State | |
| Destination Country | |
| Specific Phase of Flight | Descent |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:35AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | 0 |
| Runway Width | 0 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |