ANC09LA017

NTSB accident investigation · Cessna 207A · Hoonah, AK · December 31, 2008

Accident · No injuriesLimited investigationFinal report
Date
December 31, 2008, 10:40 local (14:40 UTC)
Place
Hoonah, AK
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N39AKCessna 207A
Defining event
Enroute-cruise: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report May 12, 2009
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA AL-JNU FSDO 05
FAA report
20081231857469A
Case key
73191

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to ensure that the aft cargo door was properly latched and locked prior to departure, which resulted in an in-flight opening of the aft cargo door and subsequent damage to the airplane.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Doors: cargo/baggage doorsAircraft › Aircraft structures · Incorrect use/operationCessna 207A: 1 caseAll aircraft: 9 casesProbable cause
Action: incomplete actionPersonnel issues › Action/decision · PilotCessna 207A: 1 caseAll aircraft: 105 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 207A: 2 casesAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot departed on a VFR commuter flight when about 10 minutes after takeoff the aft cargo door opened. The door, which is hinged to open in a rearward direction, struck the right side of the fuselage, producing structural damage to the fuselage and door. The flight continued to its destination and landed without incident. No cargo or mail was lost during the event. According to the airplane's information manual, the forward cargo door is opened first. The aft door can then be opened by grasping the red handle on the forward edge of the door, and pulling downward to release its locking pawls. The cargo doors may be locked from the inside or outside, and the airplane manual states that "Both doors must be securely closed and the forward door locked prior to flight..." During a telephone conversation with the NTSB Investigator-In-Charge, the director of maintenance for the operator reported that during his postaccident inspection of the airplane, he did not detect any malfunction of the cargo door latch mechanism.

Factual narrative

On December 31, 2008, about 1040 Alaska Standard time, a Cessna 207A airplane, N39AK, sustained substantial damage when the aft cargo door opened in flight, about 7 miles north-northeast of Hoonah, Alaska. The airplane was being operated as a visual flight rules (VFR) commuter flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated as Flight 15, by Wings of Alaska, Juneau, Alaska. The commercial certificated pilot, and the sole passenger, were not injured. Visual meteorological conditions prevailed, and VFR company flight following procedures were in effect. The flight originated at the Juneau Airport about 1029, and was en route to Hoonah. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on January 5, 2009, a Federal Aviation Administration (FAA) inspector, Juneau Flight Standards District Office (FSDO), reported that the airplane was in cruise flight at 3,000 feet msl, over the Sisters Island VOR, when the aft cargo door suddenly opened. The door, which is hinged to open in a rearward direction, struck the right side of the fuselage, producing structural damage to the fuselage and door. The flight continued to Hoonah, and landed without incident. No cargo or mail was lost during the event. According to the Cessna 207A information manual, Section 7 states, in part, that the forward cargo door is opened by pivoting the door handle outward from its recessed position near the aft edge of the forward door, and then pulling outward on the handle. After the forward door is opened, the aft door may be opened by grasping the red handle on the forward edge of the door, and pulling downward to release its locking pawls. The cargo doors are locked from the inside by rotating the inside handle counterclockwise to the "Locked" position, and when locked, the door cannot be opened from the outside. The outside cargo door handle can be used to lock the forward door by pivoting the handle out of its recess, and moving the vertical tab of the connecting link outward from behind the handle to engage a detent at its forward end. Pushing the handle back into its recess will rotate the inside handle toward the locked position. The handle can then be locked via key. The information manual notes that, "Both doors must be securely closed and the forward door locked prior to flight..." During a telephone conversation with the NTSB IIC, on January 5, the director of maintenance for the operator reported that he inspected the airplane in Hoonah on December 31. He said he did not detect any malfunction of the cargo door latch mechanism.

Aircraft

Registration
N39AK
Reported as
Cessna 207A
Category
Airplane
Serial number
20700597
Airframe hours
26,106
Engine
Continental IO-520, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Alaska Juneau Aeronautics Inc., doing business as Wings of Alaska
Registered owner
Wings Airline Services Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · December 1, 2008 · 53 hours before
Departed
PAJN · Juneau, AK
Destination
PAOH · Hoonah, AK
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
19 °F, dew point 5 °F
Altimeter
29.68 inHg
Observed at
PAOH, 7 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N39AK · 1

Matched to the same aircraft by N-number and date.