# NTSB ATL97IA042: Boeing 727-232, N416DA, Atlanta, GA, February 13, 1997 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: February 13, 1997, 12:17 local (17:17 UTC) - Place: Atlanta, GA - Location: 33.6380° N, 84.4105° W: Placed by OpenAirDocs from NTSB’s distance and direction from HARTSFIELD/JACKSON ATLANTA INTL (ATL), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.6380&lon=-84.4105&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 92 uninjured - Status: Completed, report October 31, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 3788 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL97IA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3788/pdf - Page: https://openairdocs.org/ntsb/ATL97IA042 ## Probable cause failure of ground service personnel to properly close the aft cargo door before the airplane departed. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, takeoff - door,cargo/baggage - not secured (cause) - aircraft preflight - inadequate, ground personnel (cause) ## Analysis After normal pushback and taxi to the runway, the airplane began a takeoff. During the takeoff roll, the aft cargo door light illuminated on the second officer's panel. The takeoff was continued. After climbing about 900 feet, there was a 'pop' and pressurization was lost. The pilot returned to the departure airport. Subsequent examination revealed that the door latch should have functioned properly, and the cargo light should have been illuminated, if the door was not closed. None of the ground crew remembered latching the cargo door. ## Factual narrative On February 13, 1997, about 1217 eastern standard time, the aft cargo door of a Boeing 727-232, N416DA, opened during takeoff from The William B. Hartsfield-Atlanta International Airport, Atlanta, Georgia. The airplane, Flight 1180, was operated by Delta Air Lines as a scheduled, domestic, passenger flight under the provisions of Title 14 CFR Part 121, and instrument flight rules. Instrument meteorological conditions prevailed. An instrument flight plan was activated. There were no injuries to the airplane's occupants, and the airplane had minor damage. The flight, which was originating at the time of the incident, was destined for Charleston, South Carolina. The captain of Flight 1180 stated that the pushback and taxi were "normal with all lights extinguished." He noted, "during takeoff roll, the aft cargo light on the second officer's panel illuminated, cabin pressurization was normal." When the airplane reached approximately 900 feet, there was a "pop", and the airplane lost pressurization. A passenger noticed the cargo door had opened and brought it to the attention of a flight attendant. According to the pilot, the #3 engine then experienced difficulties. There was a "decrease in EPR, N1, and N2 and the engine failed." The airplane returned to Atlanta for an uneventful landing. According to Delta's Operating Manual for the Boeing 727, the cargo light is on the Second Officer's panel and checklist. During the Captain's pre-flight checklist, he inquires as to whether the Second Officer completed his checklist. The Captain and First Officer do not visually check the Second Officer's panel for illuminated lights. According to Delta's records, the Second Officer had 1216 hours of total flight time in the 727, and 179 hours in the last 90 days. The Second Officer was originally hired in October 1991, furloughed in October 1993, and recalled in June 1996. He had 372 hours in the 727 since he was recalled. It was later noted that one bag fell out of the baggage hold onto the runway. Subsequent examination of the airplane did not reveal any structural damage to the airframe. The same cargo door was removed for minor repairs, and was re-installed on the airplane. The latching mechanism was examined and was found capable of smooth operation. There was no damage to the door's locking hooks. An electrical continuity check of the door warning circuitry was positive, and the bulb in the cockpit warning light would illuminate. According to Delta, all of the ground personnel interviewed stated they did not lock the cargo door. They were unable to determine who last operated the cargo door. ## Aircraft - Registration: [N416DA](https://openairdocs.org/deregistered/N416DA-2013-07-11), registration cancelled 2013-07-11, S/N 21258, built 1976 (OpenAirDocs) - Reported make and model: Boeing 727-232 - Registry model: [Boeing 727-232](https://openairdocs.org/model/boeing-727-232) (registry code 1384082) (OpenAirDocs) - Category: Airplane - Serial number: 21258 - Airframe hours: 21128 - Engines: P&W JT8D-15A 15500 lbs thrust turbo fan - Damage: Minor damage - Flight: Part 121 - Registered owner: Delta Air Lines - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, February 8, 1997, 32 hours before - Departed: ATL - Destination: CHS, CHARLESTON, SC - Flight plan: IFR - Airport: ATL, Hartsfield International, runway 9L, 11,889 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 13,750 total, 4,640 in this make and model, 238 in the last 90 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 70° at 15 knots, gusting 19 - Visibility: 2.5 statute miles - Lowest ceiling: 900 ft broken - Temperature: 39 °F - Altimeter: 30.00 inHg - Observed at: ATL, 1 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 19970213004729I](https://openairdocs.org/incident/19970213004729I), Feb 13, 1997: Boeing 727232, Atlanta, GA, Minor damage. Aft cargo lighto on climbout. Lost pressurization. NR3 engine failed. Returned. Cargo door open. Door hit engine. 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.