UNITED STATES O AMERICA F
TI
WASHINGTON, D.C.
ISSUED:
July 3, 1972
A d o p t e d by the NATIONAL TRANSPORTATION SAFETY BOARD a t i t s o f f i c e i n Washington, 0. C . on t h e 7 t h day of June 1972
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Honorable John H. Shaffer Administrator Federal Aviation Administration Washhgton, D. C . 20591
SAFETY RECOMMENDATIONS A-72-78
A f a t a l a i r c r a f t a c c i d e n t , which t h e National Transportation Safety Board i s c u r r e n t l y i n v e s t i g a t i n g , and a recent a i , r c r a f t incident have indicated t o t h e Board t h a t a s a f e t y problem e x i s t s on twin-engined general a v i a t i o n a i r c r a f t which have baggage compartments l o c a t e d i n t h e nose sectj.on.
The accident involved a Beechcraft 6 5 - ~ 8 0 , N84mS, which crashed on takeoff from Albuquerque, New Mexico, on May 19, 1972. Our preliminary findings i n d i c a t e that t h e nose cargo door opened during t a k e o f f . Pieces of loose cargo and t h e door were s t r u c k by t h e l e f l ; p r o p e l l e r . Tlie p i l o t feathered t h e l e f t p r o p e l l e r and declared h i s i n t e n t i o n t o land. Thr. a i r c r a f t crashed from a l e f t t u r n follotring takeoff. A l l nine occupaiits sustnincd f a t a l i n j u r i e s . This a i r c r a f t was equipped with a s a f e t y i n t e r r u p t e r switch .vi1 i , h j.:; designed t o preclude s t a y t i n e of the l e f t engine i f t h e nose carE:o compartment door i s not properly latched. However, maintenance recurdo i n d i c a t e t h a t t h e system had been inoperative f o r some time. This switch was found i n t h e wyecltage; however, t h e s e v e r i t y of t h e ensuing ground f i r e following t h e crash precluded the i n v e s t i g a t o r s from making any determinat i o n of i t s condition p r i o r t o t h e crash. T h i s a i r c r a f t d i d not liave any cargo r e s t r a i n i n g devices i n &he nose cargo compartment. The i n c i d e n t , which invglved a Beechcraft B-99 a i r c r a i t u t i l i z e d f o r a i r taxi operations, was simiiar i n nature except t h a t t h e p i l o t made a
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Honorable John H. Shaffer
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s u c c e s s f u l emergency landing on t h e remaining runway. That ciircrrPt bms equipped with a cargo r e s t r a i n t system whi.ch was nob i r i use, tinil w i t l i u door warning system which was inoperative. The Board i s concerned over t h i s i.ristan(!c w h i c h licts occurm!iI r l k s p i IA t h e safeguards designed i n t o t h e a i r c r a f t . The Board b e l i e v e s L h < iI: doub:l f a i l u r e p r o t e c t i o n on t h e s e doors i s required i r i view or t h e c:utnctrr(phj.i e consequences i f t h i s cargo door opens i n :L'light. W understand t l i d Beec 1 A i r c r a f t Corporation has recommended t h a t t h e owners of Beech 99 a i r c r a f t w i t h nose s e c t i o n cargo compartments i n s t a l l an e x t e r n a l lock t o provide double f a i l u r e p r o t e c t i o n . A l t e r n a t i v e l y , a s a f e t y chain could be i n s t a l l e d t o prevent t h e door from opening f u l l y i n f l i g h t i f it should become P unlatched. The Board f u r t h e r b e l i e v e k t h a t 14 C R 23.787 (b) whiclr provides f o r a cargo r e s t r a i n t system, i f made a p p l i c a b l e t o nose s e c t i o n cargn compartments, would prevent cargo from s h i f t i n g outward through a11 fina d v e r t e n t opening of t h e cargo compartment door i n f l i g h t .
To preclude f u r t h e r a c c i d e n t s l i n c i d e n t s of this type, t h e Safcty Bourd recommends t h a t t h e Federal Aviation Administration:
1. Provide f o r double f a i l u r e p r o t e c t i o n by means o a r secondary locking'.device o r cargo r e s t r a i n t system on those cargo doors where inadvertent opening i n f1if:h.t vou1.d s e r i o u s l y jeopardize t h e s a f e t y of f l i e h t o the f a i r c r a f t o r t h e s a f e t y of i t s occupants on all s o ai'fected aircraft.
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I s s u e an a l e r t t o a l l a i r t a x i operators, a d v i s i n g them of the hazardr: a s s o c i a t e d vi.th t,lie i.mproper s e c u r i t y of cargo doors. Consider rulemalting under P a r t 135 t o r e q u i r e a door warning system, double locking devices, and cargo r e s t r a i n t ::ystems f o r t h o s e cargo compartment doors where i n a d v e r k n t opening . r i n f l i g h t would s e r i o u s l y jeopardize t h e s a f e t y o f l i g h t of t h e a i r c r a f t or t h e s a f e t y of i t s occupants. Evaluatf t h e a p p l i c a b i l i t y of 14 C R 23.787 (b) f o r P of nose 'cargo compartment and t h e a t t e n d a n t hazard (if carg s h i f t i n g such as occurred i n t h i s accidcnt.
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This matter has been discussed with representa.tivcs ol' your Fl' Standards Service. Our Bureau of Aviation Safety Staff' i s a v a i l a b l e a d d i t i o n a l discussion i f desired.