NTSB Factual Report

HISTORY OF FLIGHT

On November 23, 1995, about 1615 eastern standard time, a Beech A36, N550RR, collided with the ground while maneuvering at the Atlantic City International (ACY) Airport, Atlantic City, New Jersey. The airplane was destroyed. The private pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed. The personal flight to Houston, Texas, was being conducted under Title 14 CFR Part 91.

The airplane had landed at ACY at 1550, after a short flight from Bater Field, because there were no refueling services at Bater. The operations personnel at Midlantic Jet Aviation, Inc., the fixed base operator (FBO), stated that the pilot came inside the office, ordered fuel, and stated that he was in a hurry, because he was going to fly to Houston, Texas, that night. The airplane was refueled with 64 gallons of 100 low lead fuel, and the pilot entered his airplane and departed. According to the FBO's refueling invoice, the pilot had arrived at their facility at 1555.

At 1607, the pilot radioed Atlantic City ground control, and requested a VFR clearance from Atlantic City, New Jersey, to Washington, DC, then on to Knoxville, Tennessee, and then to Houston, Texas. The pilot was issued a departure clearance, and he taxied to the active runway. The fight was cleared for takeoff at 1614. The airplane departed on runway 22, and at 1614:45, the pilot advised the tower controller, "...I have to come back my ah door opened up." The controller cleared the pilot to land on any runway.

The controller was interviewed, and stated, she observed the airplane climbed to an altitude of approximately 200 feet above the ground, before leveling off. She watched the airplane turn left, commence a descent, and roll almost inverted, before she lost sight of it behind some buildings. At 1615:29, the sound of an emergency locator transmitter (ELT) was heard.

A security guard located near the flight line, witnessed the airplane flying over the Air National Guard area, and then lost sight of the airplane for a few seconds. The security guard stated the airplane, "...appeared to be in trouble." When the security guard next saw the airplane, it was over one of the buildings, and he stated, "...[the airplane] was inverted with the roof of the plane facing me and was still rolling." The security guard was the first on the scene of the crash and stated, "...I approached the scene...noticed fuel, and a door on the flight line side of the plane was open...a door on the right side of the airplane."

A fire fighter, employed by the Atlantic City Airport, Fire Department, stated in his summary report, "...regarding the status of the victim when first found in [the] aircraft, at no time did I see a seat belt on the victim, remove a seat belt, or see anyone remove a seat belt." When rescue personnel arrived they found an open door on the airplane. According to the fire department report, "...in regards to the partially open door on the starboard side of the aircraft it was the door with the opening facing the aft of the aircraft and when I first arrived I pulled the door open to allow me to make entrance into the aircraft."

The accident occurred during the hours of daylight approximately 39 degrees, 27 minutes north, and 74 degrees, 34 minutes west.

PERSONNEL INFORMATION

Information on the pilot is contained in this report on page 3, under First Pilot Information. The pilot's personal logbook containing his flight hours was not found.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time of the accident. Meteorological information is contained in this report on page 3, under Weather Information.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot, on November 24, 1995, at the Shore Memorial Hospital, in Somers Point, New Jersey, by Dr. Lyla Perez.

Toxicological tests on pilot were conducted at the Toxicology Laboratory, Federal Aviation Administration, Oklahoma City, Oklahoma, and revealed "no drugs or alcohol."

WRECKAGE AND IMPACT INFORMATION

The airplane impacted in an area of the airport operated by the Air National Guard, and came to rest inverted, partially hanging over a cement embankment, approximately 1 mile south of the departure runway. All the parts of the airplane were found within the impact area. There were no ground scars observed, and no indication of any fore or aft movement, after impact. The wreckage was oriented on a heading of 225 degrees.

Both wings had remained attached to the fuselage, with the flaps and ailerons still attached. Both flaps were found in the retracted position. Both wings displayed crushing of the leading edges aft to the forward spar. The nose of the fuselage was crushed. The leading edge skin in the area of the fuel tanks, was peeled back to the forward spar, exposing the fuel bladder. Both tanks had been breached and no fuel was observed.

Examination of the empennage did not revealed any discrepancies, and all the control surfaces were attached to the main structure. The elevator trim tabs were found set at about 6 degrees tab up. Control continuity was established from the tail through the aft cabin.

The cabin area was exposed, and destroyed forward of the spar. All the instruments and switches were destroyed, rendering them either unreliable or unreadable. The aft cabin area displayed very little damage. The two aft cargo/utility doors were found attached to the fuselage, and according to the first rescue personnel to arrive at the crash site, the right side cargo door was "open." Examination of the "D" ring, exterior door handle, on the forward, of the 2 cargo doors, revealed it was in the "open" position. The handle was found stuck in a position oriented at 1:00 and 7:00 o'clock, which is not fully latched. The door is fully latched when the handle is at the 3:00 and 9:00 o'clock position. Examination of the door locking pins, revealed that the upper and lower pins did not engage the locking holes. The inner lining of the forward cargo door was removed to allow examination of the door rods and latches. All the rods were in place and moved with out restrictions when activated by hand. No discrepancies were observed with the door's latches or rods.

The right side, forward cabin door, displayed paint scraping from the periphery of the door frame, fore and aft crushing of the forward edge of the door, and the upper door latch was found in the latched position.

The landing gear and gear actuator were found in the retracted position. The fuel selector was selected to the "LEFT" tank position. The throttle, propeller and mixture controls were found in the full forward position.

The engine, with the propeller, had separated from the airframe. One propeller blade was bent opposite the direction of rotation, with cordwise scratches across the cambered side. The other blade was bent forward opposite the direction of rotation. An examination, and partial disassembly of the engine did not reveal any discrepancies.

ADDITIONAL INFORMATION

The aircraft wreckage was released to Mr. Ken Crudent, airport operations, on November 24, 1995, and subsequently to the owner's insurance company.

NTSB Probable Cause

the pilot's failure to maintain control of the airplane. A factor was the pilot's diverted attention due to an open aft cargo door.