Open Door to Disaster
By Peter Garrison
August 2008
In January of last year, the nose baggage door of a Cessna CE-525 CitationJet opened during takeoff from Van Nuys Airport. Moments later, the jet crashed into an empty lot in a residential neighborhood just north of the airport, killing both pilots.
As you might expect at a busy airport, many people who knew something about airplanes watched the takeoff. Witnesses at midfield reported that the baggage door was closed as the airplane passed them; others near the departure end of the runway said that it was open and standing upright. A pilot holding short of the runway at an intermediate location, past midfield, reported that the Citation passed in front of him at about 100 feet, slow, and that the nose came down in what he interpreted as "an attempt to gain airspeed and control." He was on the right side of the Citation, and said nothing about the baggage door.
All witnesses -- they included the pilot of a 414 who took off right behind the Citation and maneuvered to avoid the fireball from the crash -- agreed that the jet, which reached an altitude of around 200 feet, seemed slow, and that it turned slightly left before leveling out and beginning to descend with the wings rocking slightly. It then banked sharply to the right, apparently having stalled, and crashed in a wings-vertical attitude.
Before the crash, one of the CitationJet's pilots told the tower that they wanted to return for landing, and the tower asked whether they wanted Runway 34, from which they were departing, or Runway 16. The answer was 34, and a few seconds later the tower cleared the crew to land the jet on any runway.
Some reported seeing objects fall from the baggage compartment and enter the left engine; but a thorough search turned up nothing between the runway and the crash site, and the two 1,900-pound-thrust Williams engines gave no evidence of foreign object ingestion. There was nothing, in fact, to indicate that the engines had not been operating normally, or that they were not able to produce full power, at any time during the accident sequence.
The wreckage was heavily fragmented and partially consumed by fire, but investigators were able to establish that the key lock on the left baggage door had been in the unlocked position. The baggage door is normally held shut by two mechanical latches, one at each end, and further secured by a central key lock. A warning light on the instrument panel illuminates if the key lock is not engaged, but it is the mechanical latches that actually hold the door shut.
Line personnel who had serviced the airplane before takeoff reported seeing the second pilot load some items into the nose baggage compartment and lower, but not latch or lock, the left-side door. The airplane was then towed away from the fuel pit for start. Because the line crew had to leave briefly to marshal out another airplane, no witnesses could describe the exact sequence of events as the two pilots boarded the airplane for a 20-mile positioning flight to Long Beach. One reported, however, that the senior pilot, a 72-year-old ATP (who held ratings for several Boeings as well as the L-1011 and the MD-11 and was the founder and owner of the charter service operating the Citation), was in the left seat. The right-seat pilot, 49, had 1,700 hours and was qualified as a second pilot for Part 135 flights. Line personnel reported that the delay before engine start -- about 10 minutes -- was unusually long.
The National Transportation Safety Board did not pretend to understand the precise sequence of events that led to the crash, which it attributed simply to failure to maintain flying speed. It identified as contributing factors the improper preflight inspection by the second pilot, his failure to secure the baggage door, and the "likely" distraction of the first pilot by the door flying open.
There was nothing to quarrel with in this finding of probable cause, but a number of aspects of the accident remained mysterious. Did the pilots not receive any warning of the unlocked door? In theory, at least, an unlocked baggage door would have lit up both an amber warning light and the master caution light on the annunciator panel. The master caution light could be reset by the pilots, but the door-specific warning light would remain illuminated. Warning lights could be tested -- a pre-takeoff checklist item -- and so a failure of the door warning light bulb could be identified if the master caution lit up without any corresponding specific warning light.
The NTSB implies that the first pilot was the pilot flying, although it does not identify the radio transmission as coming from the second pilot. If it was the highly experienced first pilot -- he had 38,000 hours and 800 in type -- who allowed the CitationJet to stall, then the accident highlights the fact that experience is not necessarily a protection against fundamental errors -- and there is no more fundamental error than failure to maintain flying speed.
Discuss this article in our forums
| 
Copyright @ 2009 Bonnier Corp. All Rights Reserved. Reproduction in whole or in part without permission is prohibited.
