02 June 2011

Open Door Beech 1900 TAIC Report

On Friday 9 April 2010, ZK-EAQ, a Beechcraft 1900D aeroplane, departed from Auckland International Airport. As the aeroplane became airborne the rear cargo door opened. The crew returned and landed the aeroplane safely. There were no injuries and minor damage only to the aeroplane. The aeroplane was being operated with a permitted inoperative warning system that provided an indication to the crew when the cargo door was unlocked. An engineer had cleared the aeroplane to operate provided a crew member visually checked that the door was closed and locked before each departure. As the aeroplane was prepared for departure, the loader closed the cargo door but did not fully rotate the handle to lock the door. The first officer was distracted during the final pre-flight inspection of the aeroplane and did not positively check the condition of the door. The captain and first officer did not adequately confirm that the cargo door had been visually checked and confirmed locked before departure. As the aeroplane was taxied, the door handle vibrated loose, allowing the door to open during the take-off. As a result of the safety actions taken by the operator, the Commission did not need to make any recommendations.

Key Lessons:
The lessons to be learned from this incident were relevant to all pilots and included:
  • cargo doors and other openings on an aircraft must be securely latched and positively checked before flight,
  • the need to strictly follow and complete checklists, and
  • should there be an interruption of a checklist, the checklist should be recommenced either from the beginning or the last confirmed item completed.
For a link to the full report see : http://www.taic.org.nz/ReportsandSafetyRecs/AviationReports/tabid/78/ctl/Detail/mid/482/InvNumber/2010-004/language/en-US/Default.aspx

For photos of the incident see : http://3rdlevelnz.blogspot.com/2010/04/air-conditioned-beech-1900.html



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