5

N A T I 0 N A L

T R A N S P 0 R T A T I 0 N

S A F E T Y

B 0 A R u

-

I

-

File No. 3-0006

AIRCRAFT ACCIDENT REPORT ROSS AVIATION, INC.

Albuquerque, New Mexico May 19, 1972

Adopted: December 13, 1972

BEECHCRAFT 65B80, QUEEN AIR, N841NS

NATIONAL TRANSPORTATION SAFETY BOARD Washington, 0. C. 20591

Report Number: NTSB-AAR-72-32

TECHNICAL REPORT STANDARD TITLE PAGE . ReDort No. I 2.Government Accession No. I 3 . R e c i ~ i e n t ' s Catalog No.

NTSB-AAR-72-32 -

. T i t l e and S u b t i t l e A i r c r a f t A c i d ,,t Report - Ross Aviation, Inc., Beechcraft 65-&, Queen Air,

5.Report Date

N84lNS, Albuquerque, New Mexico, May 19, 1972

8.Performing Organization '. Author(s1

. December 13. 1972 6.Performing Organization

Code

Report No.

I. Performing Organization Name and Address National Transportation Safety Board

10.Work U n i t No.

Washington, D. C. 20591 I l .Cont rac t o r Grant No. Bureau of Aviation Safety

I3.Type o f Report and Period Covered

2.Sponsoring Agency Name and Address Aircraft Accident Report May 19, 1972

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20591 F 1 .Sponsoring Agency Code

I

l5.Supplementary Notes

This report contains Aircraft Safety Recommendations A-72-78 through 81.

16.Abstract

!rashed shortly a f t e r takeoff from Albuquerque International Airport, Albuquerque, Jew Mexico. The a i rc raf t was destroyed by impact forces and postimpact f i re . A l l line persons on board received f a t a l injuries.

Ross Aviation, Inc., F l i g h t 7 of 19, 1972, a scheduled air taxi flight,

)pened and was struck by the l e f t propeller. Cargo from the compartment wa6 also itruck by the same propeller. The p i lo t shut down the l e f t engine, continued his xkeoff, and requested clearance for an immediate landing.

Shortly a f t e r the start of takeoff roll, the forward cargo compartment door

;his accident was the inadvertent opening of the forward cargo compartment door and The National Transportation Safety Board determines tha t the probable cause of

;he subsequent discharge of cargo, which caused damage t o the l e f t propeller and addi Gional drag a t a c r i t i c a l phase of f l ight . The Safety Board believes tha t had the loor-unsafe-indicating system been operational or had the security of the forward :argo compartment door been ensured, the accident would have been avoided.

Four recommendations have been made t o the Federal Aviation Administration.

17. Key Words 118.Ois t r ibu t ion Statement Airlines, scheduled air taxi, takeoff, impact forces, f i r e , cargo compartment door, miemswitch, latch, roll distribution

Released t o public

t o the l e f t .

19.Security C lass i f i ca t i on 22.Price 21.No. o f Pages 2O.Security C l a s s i f i c a t i o n (o f t h i s repor t )

UNCLASSIFIED UNCLASSIFIED (o f t h i s page)

16

NTSB Form 1765.2 (11/70) ii

TABU OF CONTEJ!EPS

Synopsis . . . . . . . . . . . . . . . . . . 1 Investigation . . . . . . . . . . . . . . . 2 Analysis and Conclusions . . . . . . . . . . 4 Probable Cause . . . . . . . . . . . . . . . 7 Recommendations . . . . . . . . . . . . . . 7

Appendices

Appendix A - Crew Information Appendix B - Aircraft Information Appendix C - Safety Recommendations to the

Federal Aviation Administrator and Response

tion relevant to the probable cause and safety message to This report contains the essential items of informa-

be derived from this accident/incident. However, for those having a need for more detailed information, the original

Washington office of the National Transportation Safety factual report of the accident/incident is on file in the

mercially at an average cost of 15$ per page for printed Board. Upon request, the report will be reproduced com-

matter and 85q per page for photographs, plus postage. (Minimum charge is $2.00.)

Washington, D. C. business firm which holds the current Copies of material ordered will be mailed from the

contract for commercial reproduction of the Board’s public files. Billing is sent direct to the requester by that firm and includes a $2.00 user service charge by the Safety

the cost of reproduction. No payments should be made to Board for special service. This charge is in addition to

the National Transportation Safety Board.

Requests for reproduction should be forwarded to the:

National Transportation Safety Board Administrative Operations Division Accident Inquiries 6 Records Section Washington, D. C. 20591

F i l e No. 3-0006

NATIONAL TRANSPORTATION SAFEIT BOARD

AIRCRAET ACCIDENT REPOET WASHINGTON, D. c. 20591

Adopted: December 13, 1972

BEECHCRAFT 65-B80, QUEEN AIR, N84m ROSS AVIATION, INC.

ALBUQUERQUE, NEW "IC0 m y 19, 1972

SYNOPSIS

A t approximately 1329 mountain daylight time, May 19, 1972, Ross Aviation, Inc., Beechcraft 65-&0 Queen Air, N84lNS, a scheduled air taxi

Albuquerque, New Mexico. The a i r c r a f t was destroyed by impact forces and flight, crashed short ly after takeoff from Albuquerque International Airport,

postimpact .fire. A l l nine persons on board received fatal injur ies .

Shortly a f t e r the start of takeoff roll, the forward cargo compartment door opened and was struck by the lef t propeller. Cargo from the compartment was a lso struck by the same propeller. The National Transportation Safety Board is unable t o determine the exact point i n the takeoff sequence at which the p i l o t became aware of an abnormal si tuation. The left propeller was feathered and the landing gear re t racted almost immediately after l i f t- of f . The p i l o t then started a l e f t t u r n at an a l t i t ude of 50 t o 100 fee t , and requested clearance fo r an imed ia t e landing. After a turn of approximately 180°, the a i r c r a f t rol led violent ly t o the lef t while assuming an extreme nose-low a t t i tude , and crashed.

The National Transportation Safety mard determines that the probable cause of this accident w a s the inadvertent opening of the forward cargo

the l e f t propeller and additional drag at a c r i t i c a l phase of flight. The compartment door and the subsequent discharge of cargo, which caused damage t o

t i o n a l or had the securi ty of the forward cargo compartment door been ensured, Safety Board believes that had the door-unsafe-indicating system been opera-

the accident would have been avoided. ' -.

As a result of the investigation of this accident, the Safety Board made four recommendations t o the Federal Aviation Administration. (See Appendix C. )

- 2 -

INVESTIGATION

Ross Aviation Flight 7 (Ross 7 ) , a scheduled air taxi flight between Albuquerque International Ai rpor t (ABQ), New Mexico, and Los Alamos, New Mexico, was scheduled t o depart from ABQ at 1315 m.d.t. 1/ with one p i l o t and eight passengers. The dest ination of Ross 7, a Beechcraft 65-B80 Queen Air, N84WS, had been changed t o Santa Fe Municipal Airport because of adverse winds at Los Alamos. In addition t o t he p i l o t and passengers, the a i rc ra f t carried 35 pounds of cargo i n t he rear cargo compartment, and 86 pounds of cargo i n the nose cargo compartment.

Local Controller t o taxi t o R u n w 1-7 for takeoff. A t 1323:40, Ross 7 requested and received permission from AB& Tower

takeoff from a point adjacent t o T a x i w a y 7. From t h i s point, 7,500 feet A t 1326:40, ABQ Local Controller cleared Ross 7 for an in tersect ion

of the 8,993-foot runway w a s available for takeoff. Wind was given as “. . . one niner zero degrees variable, at two two.”

Moments later, Ross 7 was observed approximately 3,500 f e e t from the point on Fiunway 17 where takeoff had been in i t ia ted. A t t h i s time, the

full- feather position. The a i r c r a f t had at tained 50 t o 100 feet of altitude flaps and landing gear had been retracted, and the lef t propeller was i n t he

remained. over the centerl ine of the runway. Approximately 4,000 f e e t of runway

Ross 7 Was then observe8 t o start a shallow l e f t turn t o a magnetic heading of approximately 350 .

A t 1328:35, Ross 7 requested, “Tower, Ross 7 for, uh, landing one seven. ” ABQ Local Controller replied, “Roger Ross 7, uh, runway two six, if you’d like, or runway one seven. W i n d is two zero degrees at two three.” Ross 7 did not acknowledge t h i s transmission, nor were any further trans- missions heard from the f l ight .

of 100 feet on the approximate heading of 350 , Ross 7 was observed t o After momentarily f ly ing straight and lege l at an estimated a l t i tude

assume a slight nose-high a t t i tude then roll t o the lef t at a rapid rate. The a i r c r a f t pitched down rapidly du r ing the ro l l i ng maneuver.

of mweys 17 and 26, i n a r&ght-wing-low, 80’ nose-dom a t t i tude a f te r completing approximately 240 of r o l l t o the left.

Ross 7 struck the ground 7,000 feet east-southeast of the in tersect ion

The a i r c r a f t w a s destroyed by impact forces and postimpact fire. The p i l o t and eight passengers sustained fatal in jur ies .

;I/ A l l times herein are mountain daylight, based on the 24-hour clock.

- 3 -

;he d e

?. "

In

?

-

Examination of the a i r c r a f t wreckage disclosed that:

1. The wing flaps and landing gear irere i n the retracted position.

2. There were no separations of s t ruc tu ra l components p r io r t o impact.

3. Propeller slash marks were found on the forward cargo compwtment door.

4. doth engines were capable of normal operation pr ior t o the time that damage w a s in f l ic ted t o the l e f t propeller.

5. The l e f t propeller was i n the feathered posit ion and the t i p had been broken off of one blade.

The forward cargo compartment door w a s recovered from the wreckage. The door locking mechanism, which w a s found i n the unlocked position, w a s checked and found t o function properly.

which slide i n t o holes i n the door frame and are held i n place by an over- This door locking mechanism consists of three bayonet-type latches

center cam. During the locking operation, which requires 40 inch-pounds of torque, the overcenter c m action has a d is t inc t ive "feel" which serves as confirmation of i t s locked position. The statement of a former Ross Aviation, Inc., p i l o t revealed that the door locking mechanism on N84ms w a s very d i f f i c u l t t o operate. It had been his experience that the d i f f i cu l ty w a s such that some company personnel were unable t o la tch the door properly.

switch system. This system w a s designed t o preclude s t a r t i n g of the l e f t engine if the forward Cargo com artment door was not latched properly. m e Deferred Discrepancy List for N 8 4 U S showed that the safety switch had been

t o the switch. inoperative f o r some time. Investigation disclosed that there was no wiring

This a i r c ra f t w a s or iginal ly equipped with an optional safety in te r rupter

Cargo from the forward cargo compartment was found on both s ides of Runway

propeller t i p from the lef t propeller of N84lNS was found at the intersect ion 17, approximately 1,400 f e e t from the beginning of the takeoff r o l l . A

of Runways 17 and 26, 2,400 f ee t from the beginning of takeoff roll. Four thousand nine hundred f ee t of usable runway remained from t h i s point t o the departure end.

The takeoff and climb performance of the Queen Air 65-B80 a$craft w a s

weight of 8,300 pounds, the l e f t engine stopped, and i t s propeller feathered computed for a 5,300-foot pressure a l t i tude , a temperature of 83 F., takeoff

at takeoff speed. These conditions approximate those associated with the takeoff of Ross 7 on the dq,.of the accident, with the exception of the open forward cargo compartment door. The calculated climb performance w a s based

- 4 -

upon the assumption that the l e f t engine was stopped and the propeller feathered at, or immediately af ter , l i f t- off . The resu l t s of these computations showed a

The single-engine best r a t e of climb speed was 96 KCAS. The corresponding takeoff speed of 93 knots calibrated airspeed (KCAS) a f t e r a r o l l of 2,600 feet .

minimum single-engine control speed (vmc), assuming level flight and takeoff power on the right engine, would be 87 KCAS and s ta l l speed calculated t o be 89 KCAS. With this configuration, the performance data indicated that the a i r c ra f t could achieve a r a t e of climb of 188 f e e t per minute.

protruding cargo door and the resul t ing cavity i n the nose compartment. The effect of the open nose cargo door on climb performance w a s therefore estimated, using a method derived fo r determining the effect of open landing gear doors. Computations thus performed indicated that t h e best rate of climb

be 94 f e e t per minute. If the p i l o t reduced this engine's power t o METO, anticipated with the door open and takeoff power on the operating engine would

the r a t e of climb would be reduced t o 31 f ee t per minute.

There is no information available for calculating the drag produced by the

manuevers and air turbulence, both of which would have also affected the stal l The climb performance would have been diminished fur ther by turning

speed adversely.

". . . temperature 81 . . . wind 220' at 24 knots, gusting t o 30 knots . . . blowing dust a l l quadrants." A special observation taken 10 minutes a f t e r the accident reported, i n par t , ' I . . . temperature 83' . . . wind 210'

AIRMCT d, val id for the time of the accident, advised of light-to-moderate at 23 knots, gusting t o 31 knots . . . blowing dust a l l quadrants." An

thermal turbulence throughout Arizona and New Mexico. Statements from p i lo t s ver i f ied the presence of this turbulence i n the t r a f f i c pat tern at ABQ.

The ASQ surface geather observation taken at 1257 reported, i n part ,

I

ANALYSIS AND CONCLUSIONS

revealed tha t the overcenter cam locking mechanism was i n an operable Examination of the forward cargo compartment door after the accident

condition. A p i l o t who had previously flown the a i rc raf t observed d i f f i cu l t i e s

door. He indicated t h a t some cargo handlers were unable t o la tch t h e door. encountered by ground crew personnel while attempting t o close and la tch the

No company records could be found t o indicate that any maintenance had been accomplished t o correct t h i s si tuation. The Safety Board believes t h a t the p i lo t , who had flown the a i r c ra f t for 24 hours i n the last 90 days, including 3 hours the deq before the accident, most l ike ly would have been aware of this

t o insure the security of the door. discrepancy. Therefore, ex t ra pref l ight precautions should have been taken

2J Maximum except takeoff.

An advisory concerning weather of such a degree as t o be potent ia l ly hazardous t o light a i r c r a f t but not necessarily hazardous t o transport- category aircraf t .

,

,

2100 ;es

- 5 -

ment were found along the sides of the runway, approximately 1,400 feet from the start of takeoff. The remaining pieces were scat tered along t he next

2,400 fee t from the start of takeoff. Accordingly, t he Safety Board makes 1,000 f ee t of runway. The l e f t propeller blade t i p w a s found approximately

the following conclusions:

The first s ignif icant pieces of cargo from the forward cargo compart-

1.

2.

3.

4.

The forward cargo compartment door cam locking mechanism w a s not fully rotated t o the overcenter pSiCion subsequent t o cargo

t h a t when the cam locking mechanism is properly positioned i n loading.' Examination of the latching mechanism design revealed

the overcenter detent, a posi t ive lock wil lpreven% inadvertent latching bayonet disengagement. The alignment of scr ibe marks on the handle assembly provides a posit ive indication that the latching bayonets a re fully engaged and t h a t the cam is m e r

posit ion would be evident if the cam were not over center. I n center. A 10' minimum displacement from the scr ibe mark alignment

th is position, the bwonets could be f u l l y engaged so that the door would otherwise appear t o be secured. The investigation disclosed that the latching device on N84ms had previously been d i f f i cu l t t o operate and required more than normal force t o

use of excessive force might have misled the p i l o t t o disregard engage the door-latching bayonets. The Board believes that the

the handle scribe-mark alignment and t o believe that the cam was over center and the door was fully locked.

The cargo door bayonet-type latches became disengaged during the takeoff r o l l and, at some point along the ground takeoff path, the door opened i n t o the l e f t propeller arco The Board believes that this occurred within the ini t ial 1,400 f ee t of the takeoff. Visual assessment of the door opening was not possible from the cockpit.

For t he next 1,200 f e e t of ground r o l l , heavy, compact metal

being struck by the l e f t propeller with suf f ic ien t force t o cargo from the forward cargo compartment was f a l l i n g i n t o and

propeller blades, and heavily dent all three blades. From the sha t te r the pieces of cargo, break off the t i p of one of the

point where the propeller blade t i p waa found, 4,930 f e e t of runww remained i n which t o s top the aircraft safely.

The a i r c r a f t l i f ted off approximately 2,600 feet from the take- off i n i t i a t i o n point. The decision t o continue f l i g h t at t h i s point was a matter of p i l o t judgment, and the known existence of precipitous t e r r a in beyond the runww might have been a factor i n t he decision t o continue. Performance data shows that the a i rc ra f t could have stopped on the remaining runway pr ior t o that point where the landing gear w a s retracted.

I

- 6 -

&

D: S

the remaining runway distance was marginal f o r a successful Subsequent t o that point, and upon reaching 50 f ee t of a l t i tude ,

rejection of the takeoff.

5. Performance calculations accounting f o r the estimated ef fec t of the open cargo door show that i n leve l flight, with the lef t propeller feathered, t he right engine operating at MET0 power, and the landing gear and f laps retracted, the a i r c r a should have had the capabili ty t o maintain a posit ive rate of climb of approximately 31 feet per minute.

6. From the deterioration of aircraft cont ro l lab i l i ty that would have been evident from the a i r c ra f t ' s flight-handling characteris- t i c s , the p i l o t would have been aware of a loss of a i r c r a f t performance capability. However, there w a s no wey that he could have made a reasonable judgment as t o the extent of loss. Under the circumstances of this in- fl ight emergency, it would be reasonable t o expect that the p i l o t would plan t o land the

ABQ tower f o r landing on either Runway 17 or 26, it is probable a i r c r a f t at the first opportunity. After being cleared by

that the p i l o t increased the angle of bank slightly i n an attempt t o land on Runway 26, the dearer of the two runweyso A t t h i s point, control labi l i ty of the a i r c r a f t w a s lost .

7. The decision of the p i l o t t o turn immediately t o another runway w a s probably influenced by the proximity of r i s i n g terrain; however, this action is questionable within the va l id i ty of the calculated performance capabili ty of the airplane with the open cargo door.

cause COmpaJ t o thc The St

been L

opera1

'J

Board i

throu, of th, a re i:

BY THI

Louis adopt:

Decem1

.s-

1

:ver, ?d

- 7 -

P R O W L E CAUSE

cause of th is accident was the inadvertent opening of the forward cargo compartment door and the subsequent discharge of cargo, which caused damage t o the lef t propeller and additional drag at a c r i t i c a l phase of f l ight . The Safety Board believes that had the door-unsafe-indicating system been

been ensured, the accident would have been avoided. operational or had the securi ty of the forward cargo compartment door

The National Transportation Safety Board determines t h a t the probable

RECO~ATIONS

As a re su l t of the investigation of this accident, the Safety Board on July 3, 1972, issued four recommendations (Nos. A-72-78 through 81) directed t o the Federal Aviation Administrator. Copies of the recommendation letter and the Administrator's response thereto are included i n Appendix C.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

/s/ JOHN H. REED Chairman

1.1 FRANCIS H. WADINS Member

/S/ ISABEL A. BURGESS Member

/ s / wmw4 R. HAJZY Member

Louis M. Thayer, Member, was not present and did not par t ic ipa te i n the adoption of t h i s report.

December 1.3, 1972.

F- - 8 -

APPENDIX A

CRFW INFOFNATION

Pi lo t Richard Thomas Zettel, aged 48, w a s a r e t i r e d Naval Aviator. He held Airline Transport Pi lo t Cert if icate No. 43920. His l a t e s t f i r s t- c lass medical ce r t i f i ca te w a s issued December 20, 1971, with the l imitat ion t h a t he m u s t w e a r corrective lenses for near vision when exercising the privi leges of his airman cer t i f ica te . He a lso held type rat ings i n Convairs 240, 340, and 440.

hours were i n Beech B80 a i rcraf t . He had flown 85 hours i n the past 9 dws, and 3 hours i n the past 24 hours. He w a s cer t i f ica ted and qualified for the operations involved.

Pi lo t Ze t t e l had accumulated approximately 5,700 hours, of which 411

I V

. He -class that vileges 340,

11.11 ' dws, x the

- 9 -

APPENDIX B

AIRCRAFT INFORMATION

The a i r c r a f t was registered t o Nationwide Airlines Southeast, Inc., Atlanta, Georgia, on November 15, 1967; t o Air South, Inc., Atlanta, Georgia, on April 9, 1969; and t o Ross Aviation, Inc., Albuquerque, New Mexico, on Jaw 29, 1970-

The t o t a l time on the a i r c r d t was 4270:05 hours. The time accumulated since the last 100-hour inspection was 34:50 hours. The last annual inspec- t ion w a s completed on January 27, 1972.

The a i r c r a f t w a s powered by two Lycoming IGSO-54O-AlD engines. The No. 1 engine, s e r i a l No. b1811-50, had been operated 1924:35 hours since manufacture, and 920:45 hours since the last major overhaul.

The No. 2 engine, s e r i a l No. L-524-50, had been operated 1716:10 hours ' 9

since manufacture and 5 7 6 : ~ hours since the last major overhaul.

Both had a t o t a l of 1471:05 hours. The a i rc ra f t w a s equipped with two Hartzell model HCB-3Z30B propellers.

1972. The a i r c r a f t was cer t i f ica ted and airworthy pr ior t o takeoff on M a y 19,

- 10 - APPFJWIX C

UNITED STATES OF AMERICA NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C.

ISSUED: July 3, 1972

Adopted by the NATIONAL TRANSPORTATION SAFETY BOARD a t i t s o f f i c e i n Washington, D. C . on the 7th day of June 1972

.................................... FORWARDED TO: 1

Honorable John H. Shaffer 1 Administrator 1 Federal Aviation Administration 1 Washington, D. C. 20591 1

1

SAFETY RECOMMENDATIONS A-72-78 thru 81

Board is currently investigating, and a recent a i r c r a f t incident have indicated t o the Board that a safety problem exis ts on twin-engin d general aviation a i r c r a f t which have baggage cmpartments located i n the 79 nose section.

A fa ta l a i r c r a f t accident, which the National Transportation Safety

The accident involved a Beechcraft 654380, N84~~s, which crashed on takeoff from Albuquerque, New Mexico, on May 19, 1972. O u r preliminary findings indicate that the nose cargo door opened during takeoff. Pieces

feathered the l e f t propeller and declared h i s intention t o land. The of loose cargo and the door were struck by the l e f t propeller. The p i l o t

a i r c r a f t crashed from a l e f t turn following takeoff. All nine occupants sustained f a t a l in jur ies .

designed t o preclude s ta r t ing of the l e f t engine i f the nose cargo

indicate that the system had been inoperative f o r some time. This switch compartment door i s not properly latched. However, maintenance records

was found i n the wreckage; however, the severity of the ensuing ground f i r e following the crash precluded the investigators from making any determina- t ion of i t s condition pr ior t o the crash. This a i r c r a f t did not have any cargo restraining devices i n the nose cargo compartment.

This a i r c r a f t was equipped with a safety interrupter switch which i s

a i r t ax i operations, was similar i n nature except tha t the p i l o t made a The incident, which involved a Beechcraft B-99 a i r c r a f t u t i l i zed f o r

t

HOI

equ SU(

doc

tht fa:

Ai : c 01

W i do t o un f0

a d cc

r e

2 1

on v ?ces l o t

- 11 - Honorable John H. Shaffer 2

successful emergency landing on the remaining runway. That a i r c r a f t was equipped with a cargo r e s t r a in t system which w&s not i n use, and with a door warning system which was inoperative.

The Board is concerned over t h i s instance which has occurred despite the safeguards designed in to the a i r c r a f t . The Board believes that double fa i lure protection on these doors is required i n view of the catastrophic

Aircraft Corporation has recommended that the Owners of Beech 99 a i r c r a f t consequences i f t h i s cargo door opens i n f l i gh t . We understand that Beech

with nose section cargo compartments i n s t a l l an external lock t o provide

t o prevent the door from opening fu l ly i n f l i g h t if it should become double fa i lu re protection. Alternatively, a safety chain could be ins ta l led

unlatched. The Board further believes t ha t 14 CFX 23.787 (b) which provides for a cargo r e s t r a in t system, i f made applicable t o nose section cargo

advertent opening of the cargo compartment door i n f l igh t . cmpartments, would prevent cargo from sh i f t ing outward through an in-

To preclude fur ther accidents/incidents of this type, the Safety Board recommends that the Federal Aviation Administration:

1. Provide fo r double f a i l u r e protection by means of a secondary locking device or cargo r e s t r a in t system on

would seriously jeopardize the safety of f l i g h t of the those cargo doors where inadvertent opening i n f l i g h t

a i r c r a f t o r the safety of i t s occupants on a l l so affected a i rc ra f t .

2. Issue an a l e r t t o a l l a i r t a x i crperators, advising them of the hazards associated with the improper security of cargo doors.

3. Consider rulemaking under Par t 135 t o require a door warnihg system, double locking devices, and cargo r e s t r a in t systems for those cargo compartment doors where inadvertent opening i n f l i gh t would seriously jeopardize the safety of f l i g h t of the a i r c r a f t o r the safety of i t s occupants.

4. Evaluate the appl icabi l i ty of 14 CF'R 23.787 (b) f o r t h i s type

sh i f t ing such as occurred i n t h i s accident. of nose cargo compartment and the attendant hazard of cargo

This matter has been discussed with representatives of your Flight Standards Service. Our Bureau of Aviation Safety Staff is available fo r additional discussion i f desired.

- 12 - Honorable John H. Shaffer 3

These recommendations will be released to the wblic on the issue date shown above. No public dissemination of the contents should be made pr io r to that date.

~ ~ ~ . .~

DE FE -

concurred in the above recommendations. Reed, Chairman, Laurel, McAdams, Thayer, and Burgess, Members,

B. @/(a John H. Reed

i

1

H C D W

D

T if

E

\” a I a

u

C

C

2

i I i

1

1

DEPARTMENT OF TRANSPORTATION - 13 -

FEDERAL AVIATION ADMINISTRATION

1 3 JilL 1972

Honorable John H. Reed Chairman, National Transpor ta t ion Safety Board Department of Transpor ta t ion Washington, D. C. 20591

Dear Mr . Chairman:

THE ADMINISTRATOR OFFICE OF

This repl ies to your safety recommendations A-72-78 through 81 issued on 3 July 1972. These recommendations w e r e concerned with reported occur rences of inadvertent ca rgo door openings on Beechcraft 65-80 and Beechcraf t 99 a i rp lanes .

We wish to advise you that cor rec t ive action has been taken t o a s s u r e a safe and proper use of the nose ca rgo door actuating sy s t em on Beechcraft 65-80 ai rplanes . A s a r e s u l t of the cited Albuquerque accident which investigation indicated was caused by non- latched nose cargo door, the F A A i ssued a safety a l e r t t o all owners and ope ra to r s on 31 May 1972. This a l e r t covered the need for positive door c losure and rigging of door actuating mechanism in accordance with the manu- fac turer ' s instructions. Subsequent examination of the door ' s t h r ee - pin latching design indicated that i f proper ly maintained and fully secured by opera tor , such provisions as specified under FAR 23.787(b) would continue to be satisfied.

With respect to the Beechcraf t 99 inadvertent door opening incident, proposed rulemalcing action i s being considered to r equ i r e a th i rd ca rgo door latch device which is in addition to the two exist ing la tches now in use. This new double fa i lure protection device is provided in accordance with Beech Service Inst ruct ion 051-113 sent t o all owners and opera tors on 20 June 1972. W e fee l that the added protection precludes need for internal tie-down provisions a s the door when fully latched is sufficient to prevent ca rgo f r o m becoming a hazard.

FAR 135.117 present ly r equ i r e s that ca rgo be c a r r i e d in an approved cargo rack, bin, or compar tment installed in the a i r c r a f t and that it

- 14 -

be s ecu red by a means approved by the Adminis t ra tor . With the proposed modification to the Beech 99, and with proper maintenance, the ca rgo compar tments of both the Beech 65 and the Beech 99 should adequately r e s t r a i n ca rgo and fulfill the requ i rements of the regulation. There fore , we do not concur that rulemdking under Part 135 be recommended.

Sincerely,

%& J. H. S affer Adminis t ra tor