2 fatal · McDonnell Douglas DC-9-33F · 1989-03-18 · SAGINAW, TX, USA
Event
NTSB number
DCA89MA035
Event ID
20001213X27869
Type
Accident
Date
1989-03-18
Location
SAGINAW, TX, USA
Injuries
Highest injury
FATL
Fatal
2
Serious
0
Minor
0
Uninjured
0
Total aboard
2
Aircraft
Make
McDonnell Douglas
Model
DC-9-33F
Registration
N931F
FAR Part
121
Engines
2
Damage
DEST
Conditions
Light
NDRK
Weather
VMC
Probable cause
THE LOSS OF CONTROL OF THE AIRPLANE FOR UNDETERMINED REASONS FOLLOWING THE INFLIGHT OPENING OF THE IMPROPERLY LATCHED CARGO DOOR. CONTRIBUTING TO THE ACCIDENT WERE: INADEQUATE PROCEDURES USED BY EVERGREEN AIRLINES AND APPROVED BY THE FAA FOR PREFLIGHT VERIFICATION OF CARGO DOOR SECURITY, EVERGREEN'S FAILURE TO MARK PROPERLY THE AIRPLANE'S EXTERNAL CARGO DOOR LOCKPIN MANUAL CONTROL HANDLE, AND THE FAILURE OF MCDONNELL DOUGLAS TO PROVIDE FLIGHTCREW GUIDANCE AND EMERGENCY PROCEDURES FOR AN INFLIGHT OPENING OF THE CARGO DOOR. ALSO CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF THE FAA TO MANDATE MODIFICATION TO THE DOOR-OPEN WARNING SYSTEM FOR DC-9 CARGO-CONFIGURED AIRPLANES, GIVEN THE PREVIOUS KNOWN OCCURRENCES OF INFLIGHT DOOR OPENINGS.