F
UNITED STATES O AMERICA
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
----------------------------~---".---
FORWARDED TO: I
1
Honorable John H. Shaffer 1
Administrator )
Federal Aviation Administration
Washhgton, D. C . 20591 )
SAFETY RECOMMENDATIONS A-72-78 thru 8 1
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 determina-
t 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
,..
;..
;
.
Honorable John H. Shaffer 2
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
consequences i f t h i s cargo door opens i n :L'light. W understand t l i d Beec 1 e
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
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
P
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 fin-
a 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.
2. 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.
3. 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.
4.. 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.
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.