NTSB Factual Report

HISTORY OF FLIGHT

On June 11, 1993, at 1719 central daylight time, a Beech 95-C55, N301U, registered to Schneider Leasing, Inc., of Sioux City, Iowa, operated by Woodbury County Sheriff's Department, and piloted by a private rated pilot, experienced a loss of control on initial climb from runway 16 (4,002' X 75' dry/concrete) at Fort Madison Municipal Airport, Fort Madison, Iowa, and impacted the terrain. The airplane sustained substantial damage. The pilot and one passenger sustained fatal injuries, while another passenger received serious injuries. The public use flight was being conducted in visual meteorological conditions under provisions of 14 CFR Part 91. No flight plan was on file. The flight was originating at the time of the accident with an intended destination of Sioux City, Iowa.

The purpose of the public use flight was to transport a prisoner from a prison facility in Fort Madison, Iowa, to a similar facility in Sioux City, Iowa.

According to witness statements the airplane with a pilot and passenger, both employees of the Woodbury County Sheriff's Department, arrived at the airport, in the accident airplane, at approximately 1648. After exchanging paperwork, the prisoner was seated in the right middle seat of the airplane in handcuffs and his seat belt was attached by one of the Woodbury County Officers. The witnesses then talked with the Woodbury County officers for about ten to fifteen minutes about the airplane. Both of the witnesses looked into the airplane during this talk. One witness stated that the prisoner was seated in the right middle seat that was described as being at the extreme rear of its travel.

At the conclusion of the talk the two Woodbury County officers boarded the airplane with the pilot occupying the left front seat and the other officer was in the right front seat. As the engines started the witnesses returned to their vehicle parked in the parking lot of the airport and waited for the airplane to depart. While the airplane taxied out to the runway, one of the witnesses stated that he noticed the door being held open and commented to the other witness that he hoped that they would close the door before their departure.

The driver of the vehicle then repositioned the vehicle while the airplane was taxiing to the end of the departure runway (16). They watched for the airplane to pass in front of their vantage point. As the airplane passed they both noticed that the airplane was airborne and the landing gear was retracted. The driver then turned his attention from the airplane and began to move the vehicle to depart the parking lot. The passenger in the right seat of the vehicle continued to watch the airplane and observed it pitch nose down and disappear, from his view, behind a hangar roof. He stated that he thought he heard a loud pop coincident with the pitch over. He then told the driver of the vehicle that the airplane had crashed. They were unable to drive their vehicle toward the runway, so they ran to where they could see that the airplane had impacted on the runway near the departure end of runway 16.

They then proceeded to the airplane where they found the two officers appeared deceased. The prisoner was still strapped to his seat which had broken from its mount, and he was breathing. They stated that the right front door was trapped open between the inverted right wing and runway. They stated they did not touch the door and that they were able to get to the occupants through the opened door.

Repeated attempts to interview the surviving passenger proved negative as he denies recollection of the events surrounding the accident.

PERSONAL INFORMATION

The pilot held a private pilot certificate with privileges for single and multi-engine land airplanes. He held a third class medical certificate with restrictions for wearing glasses that corrected for near and distant vision. The medical was issued on May 15, 1992. He received his multi-engine certificate on February 10, 1992. The requirement for a biennial flight review was satisfied at that time. At the time of the accident, he had accumulated a total time of 1,935 hours with 90 hours in this make and model airplane.

AIRCRAFT INFORMATION

The airplane was a Beech 95-C55, N301U, serial number TE-209. The airplane had accumulated a total airframe time of 2,420 hours. The airplane had received an annual inspection on September 1, 1992, and had accumulated 70 hours time in service since that inspection.

WRECKAGE AND IMPACT INFORMATION

The impact marks on the runway started approximately 250 feet from the departure end of runway 16 near the west edge and continued for approximately 130 feet on a southeasterly heading to the east edge of the runway. The airplane came to rest partially inverted, on its nose. The left wing, engine and nose of the airplane were off the east edge of the runway. The wreckage came to rest on a heading of approximately 050 degrees.

The airplane remained essentially intact. A verification of the flight and engine controls was conducted and no evidence of preimpact anomalies were discovered. Both propeller's cambered faces were damaged with deep scratches and the blades from the right propeller hub were released. Both propeller shafts were fractured and broke away from their respective engines.

Although fuel had leaked from both wing tanks, approximately 30 gallons of fuel was drained from both tanks.

A check of both engines revealed that rotation was not possible due to interference crushing of the propeller nose cases on both engines. Removal of valve covers and spark plugs revealed no pre-impact anomalies. Fuel was found in both mechanical fuel pumps and the fuel pump drives were intact. Magnetos from both engines were field tested and found to operate.

The main cabin/cockpit door, situated on the right side of the airplane was found open at the impact site. After righting the airplane the door and door latching mechanism were examined and the door latch was found in the closed, but not latched position. No damage was found to the upper door hook or its corresponding latching pin. There was no damage to the lower mechanical locking bolt or its corresponding hole in the door frame. The rear locking bolt showed some bending; however, the striker plate and structure surrounding the rear locking bolt and striker plane showed no evidence of deformation. Scratches from impact with the runway on the exterior top of the door and adjacent roof area of the airplane, aligned when the door was held in an open or partially opened position. When the door was closed the scratches did not line up.

MEDICAL AND PATHOLOGICAL INFORMATION

Post mortem examination of the pilot of the pilot was conducted at the Keokuk Area Hospital, Keokuk, Iowa, on June 12, 1993. Cause of death was listed as multiple injuries resulting from an airplane crash. Toxicological tests performed were negative with the exception of nicotine.

ADDITIONAL DATA/INFORMATION

The parties to the investigation were the Federal Aviation Administration, Des Moines Flight Standards District Office, Des Moines, Iowa; Continental Motors, Mobile, Alabama; and Beech Aircraft Corp., Wichita, Kansas.

The wreckage was released to representatives of the owner of the aircraft on June 13, 1993.

NTSB Probable Cause

the pilot-in command's failure to maintain control of the aircraft. Factors were door not secured, checklist not followed, diverted attention of the pilot-in-command, and emergency procedure not followed.