NTSB CEN12FA606 — 2012-09-05 · Fort Worth, Texas, United States

Aircraft involved

N69924 Cessna 421B Serious

Probable cause & findings

The pilot's failure to maintain airplane control on takeoff, which resulted in an inadvertent stall. Contributing to the accident were the unlatched nose cargo door, the pilot’s diverted attention, and the pilot's mental ability to handle the emergency situation.

Factual narrative

HISTORY OF FLIGHT

On September 5, 2012, at 0949 central daylight time, N69924, a Cessna 421B twin engine airplane, sustained substantial damage after colliding with trees shortly after takeoff from Fort Worth Spinks Airport (FWS), Fort Worth, Texas. The airline transport rated pilot and the passenger were seriously injured. A visual flight rules flight plan was filed for the flight that was destined for Stinson Municipal Airport (SSF), San Antonio, Texas. Visual meteorological conditions prevailed for the flight conducted under 14 Code of Federal Regulations Part 91. There were several witnesses to the accident. One witness was an air traffic controller, who had cleared the airplane for takeoff on Runway 17R. He said that as the airplane passed by the control tower on the takeoff roll, both engines sounded normal and were in sync. The airplane rotated near taxiway foxtrot and began a "low and slow" climb. When the airplane was approximately 200 feet high, the pilot announced that a door had popped open and he needed to return to land. The controller approved the request. He then saw the airplane make a right turn followed by a left turn and then collide with trees in a left "side slip." He said it was approximately two seconds from the time the pilot reported the open door to the time the accident occurred. Two Federal Aviation Administration (FAA) maintenance technicians were working near the departure end of Runway 17R when they first saw the airplane. According to one of the technicians, he said the airplane was approximately 150 feet away from him as it passed by from his right to left. He said the airplane was low and slow and not climbing as expected. The airplane cleared the airport perimeter fence by approximately 30-50 feet. The technician said the airplane then began to “fish tail” and was about to stall. He said the airplane’s left wing dipped down followed by the right wing, then back to the left. The airplane then collided with the trees in a left yaw and caught on fire. The technician said the engines were operating and were in sync, but he could not specifically recall if the engines were operating at full power due to the prevailing wind which may have reduced the decibel level of the engine noise. The technician did not remember seeing any doors open on the airplane. The pilot said that he performed a preflight inspection of the airplane and remembered "banging" on the nose cargo door. He said the door was latched, but not locked. After the inspection, he and the passenger got on board the airplane. The pilot sat in the front left seat, and the passenger sat directly behind the pilot in the aft facing seat. The pilot said that he started the engines; taxied to the runway, performed an engine run-up, and then departed. He said he performed a reduced power (approximately 80 percent) takeoff, which resulted in a longer than normal takeoff roll. The pilot said that as soon as he rotated the airplane at “blue line” and began to climb, the nose cargo door popped completely open. The door appeared like it was going to come off the hinges and into the cockpit. The pilot said he then turned around and told the passenger that the cargo door had popped up and they had to return and land. Then he called air traffic control. Within seconds, the pilot felt the airplane shudder as if it was about to stall, so he immediately lowered the nose. The airplane collided with trees; then hit the ground hard, flipped over, and caught on fire. The pilot was able to open the main door and both he and the passenger exited to safety. The pilot said there were no mechanical problems with the airplane and that he was fixated on the unlatched nose cargo door and lost control of the airplane. He said he was dealing with a lot of stress in his personal life and was not prepared to handle the emergency situation. The passenger said that when the airplane began to climb, it seemed slower than normal. At that point, the pilot turned around and told him a cargo door had opened and they needed to go back and land. The passenger had to turn around in his seat to hear what the pilot was saying, and when he looked forward, he realized that they were going to crash. He did not see the nose cargo door. The passenger said the airplane “dipped” before it made a descending left-hand turn toward the ground. He said he immediately turned around and tightened up his seatbelt before the airplane hit the ground hard and flipped over.

PERSONNEL INFORMATION

The pilot held an airline transport pilot rating for airplane multi-engine land along with a commercial certificate for airplane single-engine land. He also held an airframe and power plant mechanic certificate. The pilot’s last FAA First Class medical was issued on December 9, 2011, with a restriction for glasses. He reported a total of 3,800 hours of which 897 hours were in the same make and model as the accident airplane.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest in clearing surrounded by small trees and brush on a heading of 240 degrees. The wreckage was inverted and mostly consumed by postimpact fire. The initial impact point was a stand of 20-30 foot tall trees. Numerous cut branches were strewn around the wreckage path that exhibited flat, angular cuts. The entire airplane was accounted for at the accident site. The initial impact point from where the airplane struck the trees to where the wreckage came to rest was approximately 150-200 feet. Examination of the airplane revealed the flaps were in the fully retracted position and the landing gear was in the down and locked position. The elevator trim was neutral and the aileron trim was pulled beyond it's stop from impact forces. Flight control continuity was established for all flight control surfaces to the cockpit. The left aileron cable was broken and one of the fractured ends exhibited broom straw signatures. The other end was melted into a melted section of the wing. The aileron sector was thermally damaged. Examination of both engines revealed no mechanical deficiencies that would have precluded normal operation at the time of the accident.

METEOROLGICAL INFORMATION

Weather at FWS at 0952 was reported as wind from 210 degrees at 4 knots, visibility 10 miles, clear skies, temperature 30 degrees Celsius, dew point 19 degrees Celsius, and a barometric pressure setting of 29.92 inches of Hg. The commercial pilot was distracted by the nose cargo door popping open during takeoff; the airplane stalled and collided with trees off the end of the runway. The pilot said there were no mechanical problems with the airplane or engines and that he was fixated on the cargo door and lost control of the airplane. He also said that due to stress, he was not mentally prepared to handle the emergency situation. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

C Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
F Personnel issues-Psychological-Mental/emotional state-Stress-Pilot - F
F Aircraft-Aircraft systems-Equipment/furnishings-Cargo compartments-Malfunction - F
F Personnel issues-Psychological-Attention/monitoring-Attention-Pilot - F

Verbatim from NTSB's published report. Source file NTSB_2012_CEN12FA606.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

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