# NTSB ATL91IA044: British Aerospace BAE Jetstream 3201, N844AE, Charlotte, NC, February 1, 1991

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: January 31, 1991, 19:37 local (Feb 1, 1991, 00:37 UTC)
- Place: Charlotte, NC
- Location: 35.2271° N, 80.8431° W: Placed by OpenAirDocs: center of Charlotte, NC, within about 10 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=35.2271&lon=-80.8431&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 5 uninjured
- Status: Completed, report May 5, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 8343
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL91IA044
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8343/pdf
- Page: https://openairdocs.org/ntsb/ATL91IA044

## Probable cause

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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Miscellaneous/other, standing - pre-flight
  - door,entrance stair - not secured (cause)
  - checklist - not followed, pilot in command (cause)
- Miscellaneous/other, climb - to cruise
  - door,entrance stair - loss,total

## Aircraft

- Registration: N844AE (not matched to a registry record)
- Reported make and model: BRITISH AEROSPACE BAE JETSTREAM 3201 (BAE JETSTR)
- Category: Airplane
- Serial number: 844
- Engines: GARRETT TPR331-12UAR 1050 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.

- Pilot; age 37; 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 (OpenAirDocs).

- [Incident 19910131001309I](https://openairdocs.org/incident/19910131001309I), Jan 31, 1991: Bag JETSTM3201, Charlotte, NC, Minor damage. Aircraft passenger door blew open and separated on climb. Returned and landed without incident.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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