ATL91IA044

NTSB incident investigation · British Aerospace BAE Jetstream 3201 · Charlotte, NC · February 1, 1991

Incident · No injuriesIncident investigationFinal report
Date
January 31, 1991, 19:37 local (Feb 1, 1991, 00:37 UTC)
Place
Charlotte, NC
Injuries
5 uninjured
Damage
Minor damage
Phase of flight
Standing
Aircraft
N844AEBritish Aerospace BAE Jetstream 3201
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 5, 1993
Report
Approved by Office Director
FAA report
19910131001309I
Case key
8343

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

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Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The failure of the captain to follow checklist procedures, resulting in a flight with the cabin door unsecured, and the subsequent loss of the cabin door.

Analysis

After the no. 2 engine started, the flight crew noticed a cabin door open light. The captain shut down the no. 1 engine, and signaled to the ground crew to check the door. The captain recycled the door warning circuit breaker several times, and the light extinguished. On climbout, passing 7,000 feet, the cabin door suddenly separated from the airplane. The flight returned to the departure airport and landed without further problems. The investigation revealed that the ground crew did not understand the captain's intentions, and did not check the door for security. The captain did not follow checklist procedures for dealing with a door light on the ground. The ramp agent, the last person to close the door, had not operated jetstream doors prior to the day of the incident. Examination of the aircraft and the recovered door revealed no evidence of malfunction or failure.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherStanding - pre-flight
Door,entrance stair - not securedCause
Checklist - not followedPilot in commandCause
Miscellaneous/otherClimb - to cruise
Door,entrance stair - loss,total

Aircraft

Registration
N844AE
Reported as
British Aerospace BAE Jetstream 3201 (BAE JETSTR)
Category
Airplane
Serial number
844
Engine
Garrett TPR331-12UAR, 1,050 lbs thrust, turbo prop
Damage
Minor damage
Flight
Part 135
Operator
Nashville Eagle
Registered owner
First Security Bank Of Utah
Last inspection
Continuous airworthiness · January 2, 2000
Departed
CLT · Charlotte, NC
Destination
BNA · Nashville, TN
Flight plan
IFR
Airport
CLT · Douglas Int'L

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
6,392 total · 500 in this make and model · 3,917 as pilot in command · 160 in the last 90 days · 60 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
320° at 10 knots
Visibility
25 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 12 °F
Altimeter
30.00 inHg
Observed at
CLT, 12 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.