Individually Owned: 150,657
Corporate Owned: 137,281
Carswell Afb Airport
Aircraft Accident/Incident Report
Saginaw, Texas 76161
Saturday, March 18, 1989 2:16 CST
NTSB Narrative Summary Released at Completion of Accident
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)
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 3/18/1989 |
| Event Day of the Week | Saturday |
| Time of Event | 216 |
| Event Time Zone | Central Standard Time |
| Event City | SAGINAW |
| Event State | TEXAS |
| Event Country | -- |
| Zipcode of the event site | 76161 |
| Event Date Year | 1989 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | CARSWELL AFB |
| Event Location Nearest Airport ID | FWH |
| 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 | 650 |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 221 Central Standard Time |
| Direction of event from weather observation facility (degrees) | 350 |
| Weather Observation Facility ID | FWH |
| Elevation of weather observation facility | 650 |
| Distance of event from weather observation facility (units?) | 8 |
| Time Zone of the weather observation | CST |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 25000 |
| Sky/Lowest/Cloud Conditions | Thin Broken |
| 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) | 19 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 320 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 6 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 2 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 74 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Mar 18 1989 12:00AM |
| NTSB Notification Time | 600 |
| Fiche Number and/or location -used to find docket information | 38043 |
| Date of most recent change to record | Dec 13 2000 12:31PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N931F |
| NTSB Number | DCA89MA035 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | Ground |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | McDonnell Douglas |
| Aircraft Model | DC-9-33F |
| Aircraft Series Identifier | DC-9-33F |
| Aircraft Serial Number | 47192 |
| Certified Max Gross Weight | 114000 |
| 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 | 3 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Mar 13 1989 12:00AM |
| Airframe hours since last inspection | 16 |
| Airframe Hours | 41931 |
| ELT Installed | No |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | -- |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | MCMINNVILLE |
| Aircraft Owner State | OR |
| Aircraft Owner Country | -- |
| Aircraft Owner Zipcode | 97218 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | -- |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Non-scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Cargo |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | FWH |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 208 |
| Departure Time Zone | CST |
| Destination Same as Local Flt | -- |
| Destination Airport Code | TIK |
| Destination City | OKLAHOMA CITY |
| Destination State | OK |
| Destination Country | |
| Specific Phase of Flight | Maneuvering |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Feb 21 2008 4:14PM |
| User who most recently changed record | NTSB\HAMG |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 17 |
| Runway Length | 12000 |
| Runway Width | 300 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |