Accident Details
An airline transport pilot and nine passengers departed on a Part 135 air taxi flight from a runway adjacent to an ocean bay. The airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot radioed that he needed to return to the airport but gave no reason. The air traffic control tower specialist cleared the airplane to land on any runway. While initiating a right turn, the airplane rolled sharply to the right and began a rapid descent with nose and right wing low. It crashed about 200 yards offshore, and the fragmented wreckage sank in 10-foot-deep water. Survivors were rescued by a private float plane.
A passenger reported that the airplane's nose baggage door partially opened just after takeoff and fully opened into a locked position when the pilot started the right turn. The nose baggage door is mounted on the left side of the nose, forward of the pilot's windscreen. When opened, it swings upward and is held open by a latching device. To lock the door, the handle is placed in the closed position and then locked by rotating a key lock, engaging a locking cam. With the locking cam locked, removal of the key prevents the cam from moving. The original equipment key lock allowed key removal only when the cam was engaged.
Maintenance and Inspections
Investigation revealed that the original key lock on the forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination found evidence that a plastic guard inside the baggage compartment, designed to protect the locking mechanism from baggage, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. The mechanical components of the forward baggage door latch mechanism were "on condition" items with no predetermined life limit.
On May 29, 2008, the Federal Aviation Administration issued Safety Alert for Operators (SAFO 08013), recommending visual inspection of baggage door latches and locks, additional training for flight and ground crews, and removal of unapproved lock devices. In July 2008, Piper Aircraft issued mandatory Service Bulletin 1194 (later 1194A), requiring installation of a key lock device, mandatory recurring inspection intervals, life limits on safety-critical parts of forward baggage door components, and installation of a placard with closing/locking instructions to preclude in-flight opening.
Post-accident inspection found no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on proper door operation or procedures for an in-flight opening.
Probable Cause
The probable cause was the failure of company maintenance personnel to ensure that the airplane's nose baggage door latching mechanism was properly configured and maintained, resulting in an inadvertent opening of the nose baggage door in flight. Contributing to the accident were the lack of information and guidance available to the operator and pilot regarding procedures to follow should a baggage door open in flight and an inadvertent aerodynamic stall.