# NTSB BFO93IA057: British Aerospace BAE3201, N496UE, Rochester, NY, March 23, 1993

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: March 23, 1993, 06:50 local (11:50 UTC)
- Place: Rochester, NY
- Coordinates: 43.229324, -77.660102 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.2293&lon=-77.6601&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report November 3, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 11877
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO93IA057
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/11877/pdf
- Page: https://openairdocs.org/ntsb/BFO93IA057

## Probable cause

FAILURE OF THE MAIN CABIN DOOR TO BE ADEQUATELY SECURED FOR FLIGHT FOR AN UNKNOWN REAS0N.

## Sequence of events

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

- Airframe/component/system failure/malfunction, climb - to cruise
  - door - not secured (cause)
  - door - separation

## Analysis

ACCORDING TO THE PILOT, AFTER THE MAIN CABIN DOOR WAS CLOSED BY RAMP PERSONNEL, HE HAD A DOOR AJAR WARNING LIGHT ON THE CAP PANEL.  HE REPORTED HE HAD FLOWN THE SUBJECT AIRCRAFT FOR FOUR LEGS THE PREVIOUS DAY AND A SIMILAR SITUATION OCCURRED ON THREE OF THOSE LEGS, SO HE PULLED THE CIRCUIT BREAKER AND RESET IT AFTER 10 SECONDS.  THE DOOR LIGHT WAS EXTINGUISHED, AND THE PILOTS PROCEEDED TO TAKEOFF.  DURING THE CLIMB, WHILE PASSING THROUGH 4000 FEET ABOVE THE GROUND, A POPPING SOUND WAS HEARD FOLLOWED BY A RAPID DECOMPRESSION.  THE PILOTS NOTED THAT THE MAIN CABIN DOOR WAS AJAR, BUT FOR SAFETY REASONS, THEY DID NOT GO TO INSPECT THE DOOR.  THE PILOTS SLOWED THE AIRPLANE TO 130 KNOTS INDICATED AIRSPEED, AND AFTER LANDING, THEY NOTED THE DOOR HAD SEPARATED FROM THE AIRCRAFT.  SEARCH EFFORTS WERE MADE AND THE DOOR WAS LOCATED IN A FIELD ALONG THE PATH OF THE FLIGHT.  THE DOOR WAS FLOWN TO SCOTLAND FOR FURTHER EXAMINATION AT JETSTREAM AIRCRAFT LIMITED; HOWEVER, THE EXAMINATION DID NOT DISCLOSE EVIDENCE OF MECHANICAL MALFUNCTION.

## Aircraft

- Registration: [N496UE](https://openairdocs.org/deregistered/N496UE-2007-09-12), registration cancelled 2007-09-12, S/N 900, built 1990 (OpenAirDocs)
- Reported make and model: BRITISH AEROSPACE BAE3201
- Registry model: [British Aerospace BAE JETSTREAM 3201](https://openairdocs.org/model/british-aerospace-bae-jetstream-3201) (registry code 1500217) (OpenAirDocs)
- Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: 900
- Airframe hours: 3144
- Engines: GARRETT TPE-331-124AR 1020 horsepower turbo prop
- Damage: Minor damage
- Flight: Part 135
- Operator: Atlantic Coast Airlines, doing business as United Express
- Registered owner: Atlantic Coast Airlines
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, March 12, 1993, 61 hours before
- Departed: BUF, BUFFALO, NY
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 4,670 total, 2,600 in this make and model, 4,200 as pilot in command, 210 in the last 90 days, 48 in the last 30 days, 6 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 90° at 8 knots
- Visibility: 15 statute miles
- Lowest ceiling: 25,000 ft overcast
- Temperature: 27 °F, dew point 19 °F
- Altimeter: 30.00 inHg
- Observed at: ROC, 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 19930323010009I](https://openairdocs.org/incident/19930323010009I), Mar 23, 1993: Bag JETSTM3201, Buffalo, NY, Minor damage. Lost main cabin door on climbout. Returned. Landed safely. Investigation continuing on loss of door.

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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