NTSB Factual Report

HISTORY OF FLIGHT

On March 27, 1994, at 1355 central standard time, a Beech 58TC, N200DL, collided with terrain during the base turn at the Jack Edwards Airport, at Gulf Shores, Alabama. The aircraft was destroyed by impact forces and fire. The commercial pilot was seriously injured. His wife, who was a passenger, was fatally injured. The aircraft was operated under 14 CFR Part 91 by the pilot. Visual meteorological conditions existed at the time, and no flight plan was filed for the personal flight to Meridian, Mississippi. The flight was originating at the time of the accident.

A witness, who was in the airport parking lot (adjacent to Runway 17), observed the aircraft take off on runway 17. He saw a dark object, which he thought was a rag, come from the nose of the aircraft. He then saw the object hesitate over the aircraft nose, then it went up and over the fuselage. He reported that the aircraft entered a gradual left hand turn, then the aircraft bank steepened to about 90 degrees as the turn progressed. He estimated that the aircraft did not climb higher than 200 feet above the ground at any time. The aircraft bank angle was very steep, with the nose about 10 degrees low, prior to impact. He did hear the engines, and did not detect any change in engine sound while the aircraft was in flight. When queried about the weather conditions at the time of the accident, he stated that it was windy at the time, with the wind direction out of the south, down the runway.

The pilot was interviewed on December 14, 1994. He reported the following: He checked the security of the nose baggage door during his initial preflight inspection, but suspects that his wife may have opened the door while he was parking his car. He did not recheck the security of the nose baggage door after he returned from the parking lot. Otherwise, his preflight of the aircraft was "usual and standard." Ground operations were normal. On takeoff, at about 50 to 100 feet above ground level (agl), the nose baggage door opened up. He recalled that there was a lot of surface wind at the time, about 25 to 35 knots, with gusts, and out of the south. When the nose baggage door opened up, he corrected with right aileron, and rudder to crab the airplane into an attitude that would close the door. The door momentarily closed, and then opened again. He left the landing gear extended, hoping this would improve stability. At about 200 feet agl, and at about 105 knots, he entered a downwind for runway 27. He then turned base leg for runway 27. He recalls last seeing about 105 to 110 knots on the airspeed indicator, but during the base turn, he "lost speed." He could see the runway, but was at a steep descent angle. The next thing he knew, the ground was coming up quickly, and the aircraft impacted the ground in a left wing low, nose low attitude. He stated that the aircraft was "unflyable" with the nose door open. He stated that he fought to keep the door closed at all times while airborne, using aileron and rudder controls. He stated that the nose baggage door had never come open on any previous flight. He reported no problems with engine performance during the accident flight.

PERSONNEL INFORMATION

Information on the pilot is included in this report at the section titled "First Pilot Information." The pilot reported that he flew approximately 10 hours during the 90 days prior to the accident, including 4 hours in the 24 hour period prior to the accident.

AIRCRAFT INFORMATION

This aircraft was not equipped with a secondary latch on the hinged nose baggage door. In April, 1982, Beech Aircraft Company issued a Class I Service Instruction, Number 1195, Revision 1. The purpose of the service instruction was to provide a secondary latching feature for the nose baggage door. According to an aircraft logbook entry, dated March 4, 1983, Service Instruction 1195 was deferred by the customer during the annual inspection of that date.

The aircraft was repaired for hail damage, in conjunction with an annual inspection, which was entered into the aircraft logbooks with a date of March 18, 1994. According to the logbook entry, the nose baggage door skin was replaced at that time. The excerpt from the logbook is included as an attachment to this report. Additional information on the aircraft is included in this report at the section titled "Aircraft Information."

METEOROLOGICAL INFORMATION

The Jack Edwards Airport is not equipped with a weather reporting facility. The weather for the Pensacola Naval Air Station is included in this report at the section titled "Weather Information." A witness account of the weather conditions at the accident site is included in the "History of Flight" section of this narrative.

WRECKAGE AND IMPACT INFORMATION

The main aircraft wreckage came to rest about 276 feet north of the runway 27 center line, and about 3,000 feet to the east of runway 17. The main wreckage was found in an upright position. The cockpit, cabin, nose, and wing sections were burned. The right wing tip was bent upward about 10 degrees, and the fuel tank was burned. The right aileron and flap were still in place on the right wing. The outer third of the left wing was found fragmented, and dispersed throughout the wreckage path. The left aileron was partially separated from the wing, and the separated section was found along the wreckage path. Both engines were still attached to the wings; the left propeller was separated from the engine, while the right propeller was attached to the right engine.

The throwover control yoke was found in the left seat position. The landing gear actuator mechanism was in the "gear down" position. The flap actuator was found in the "30 degree down" position.

The nose baggage compartment door was found at the right side of the nose area. The door was burned, and lying on top of burned nose area structure. The door was not attached to the door frame; the hinge area was burned and melted. Both nose baggage door latches (located forward and aft on the door) were found in the open (unlatched) position. The door key lock, located adjacent to the forward latch, was in the unlocked position. The latches were manually operated at the site, and closed flush with the door surface when pressed closed. The latches would open when the center button on each latch was pushed in. The hooking mechanisms, located on the interior side of each latch, were intact.

MEDICAL AND PATHOLOGICAL INFORMATION

A post-mortem examination of the passenger was performed by the Alabama Department of Forensic Sciences, Mobile, Alabama.

TESTS AND RESEARCH

The engines were removed from the airframe and taken to the Teledyne Continental Motors facility in Mobile, Alabama for disassembly and examination. Both engines were originally built as model TSIO-520-LB (310 horse power) and were later converted to TSIO-520-WB. The engine data plates were stamped TSIO-520- LBCWB in accordance with the applicable Teledyne Continental Motors service bulletin. For details of the examination, refer to the Teledyne Continental Motors Analytical Inspection Report, included as an attachment to this report.

The propeller assemblies were shipped to the Hartzell Propeller facility in Piqua, Ohio for disassembly and examination. For details of the examination, refer to the Hartzell Propeller Teardown Report, included as an attachment to this report.

The aircraft manufacturer was requested to provide flight test data addressing aircraft performance with an open nose baggage door. Beech Aircraft Corporation leased a model 58TC and conducted a series of flight tests between September 30, 1994, and October 7, 1994. The aircraft was configured so that the nose baggage door could be opened via the cockpit, with a winch and cable assembly. A series of four test flights were conducted, progressing from a flight profile with the door partially open, to a full traffic pattern profile (including takeoff and landing) with the door allowed to open completely. The Beech engineering report reported the following conclusions: (1) No aircraft control problems were noted while performing the prescribed maneuvers, with the nose baggage door open. (2) With the nose baggage door open, there was no perceptible control buzz or other control anomalies. (3) Climb performance with the landing gear extended, flaps retracted, and the door open approximately two inches, indicated no apparent two engine climb performance degradation. (4) Climb performance with the landing gear and flaps retracted, and the door at its naturally opened position, indicated a two engine climb performance degradation of about 230 feet per minute. For additional details regarding the flight tests, refer to the Beech Aircraft Corporation Engineering Flight Test Report, attached to this report.

ADDITIONAL INFORMATION

The wreckage was released to:

Harry Brooks (Insurance Adjuster) Carson-Brooks, Inc. P.O. Box 888525 Atlanta, Georgia 30356.

NTSB Probable Cause

THE PILOT'S FAILURE TO MAINTAIN AIRCRAFT CONTROL DURING THE BASE TURN. FACTORS WERE THE PILOT'S INADEQUATE PREFLIGHT, HIGH WINDS WITH GUSTS AT THE AIRPORT, AND THE PILOT'S DIVERTED ATTENTION DUE TO THE OPEN BAGGAGE DOOR.