CEN23LA003

NTSB accident investigation · Embraer S A EMB-545 · Houston, TX · October 3, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 3, 2022, 17:40 local (22:40 UTC)
Place
Houston, TX
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N179SPEmbraer S A EMB-545
Defining event
Initial climb: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Aeronautical Accidents Investigation and Prevention Center, FAA, Flight Standards District Office
FAA report
20221003021659A
Case key
106055

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 crew failed to ensure the main entry door was locked before departure. Contributing to the accident was a corroded/jammed door sensor that provided an erroneous locked indication to the crew alerting system.

Findings · 4

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · CopilotAll aircraft: 1,391 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotAll aircraft: 1,391 casesProbable cause
Indicating/recording systemsAircraft › Aircraft systems · MalfunctionAll aircraft: 18 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · Incorrect use/operationAll aircraft: 86 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 two pilots departed on a business flight with two passengers and observed that the airplane did not pressurize during the initial climb out. As the climb continued, the crew observed a door open warning on the crew alerting system (CAS). The pilot in command (PIC), seated in the right seat, got out of his seat to check the door and attempted to push the handle down toward the locked position, but stated that “it kept coming up.” About 14 seconds after the PIC got out of his seat, the main cabin door opened inflight, which resulted in substantial damage to the door and fuselage. The PIC returned to his seat and commented several times that the second in command (SIC) had not secured the door. The flight returned to land without further incident. Postaccident examination revealed no anomalies that would have prevented the door from a normal sequence of closing, latching, and locking. A corroded/jammed locked sensor assembly was observed that erroneously indicated a locked door to the CAS when the door was actually only latched but not locked. However, the two visual locked indications on the door functioned properly, which was consistent with the crew not fully closing the door or observing the unsafe (red) visual locked indicators. During climb out, the aerodynamic forces on the door and/or airplane vibration likely caused the target for closed door sensor to move away from the sensor, which triggered the CAS door open warning. The aerodynamic forces on the door, airplane vibration, and/or the PIC’s handle movement likely allowed the door to open inflight.

Factual narrative

On October 03, 2022, about 1740 central daylight time, an Embraer EMB-545 airplane, N179SP, sustained substantial damage when it was involved in an accident near Houston, Texas. The two pilots and two passengers were uninjured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. The PIC, who was seated in the right seat and acting as pilot monitoring, stated that the SIC, who was seated in the left seat and acting as pilot flying, closed and secured the main cabin door. The crew verified that there were no CAS messages displayed on the multifunction display before they taxied for departure and before take-off. The flight data recorder (FDR) data indicated that during initial climb, the airplane was not pressurizing, consistent with the main entry door vent flap being open and the door not fully closed. Climbing through about 5,280 ft, FDR data recorded a DOOR PAX OPEN and master warning indication on the CAS. According to the cockpit voice recorder (CVR) information, the PIC got out of his seat about 12 seconds after the master warning to check the door and reported trying to push the handle down toward the locked position but “it kept coming up”. About 14 seconds after the PIC left his seat, the CVR recorded sounds consistent with the door opening in flight, which resulted in substantial damage to the door and fuselage. The PIC returned to his seat about 21 seconds after the door opened and commented several times that the SIC had not secured the door. The flight returned to land. The door contacted the runway during landing resulting in substantial damage to the airplane. Closure of the main cabin door is accomplished with either the internal or external handle, which transitions the door from the almost closed position to the closed, latched, and locked positions through a complex mechanical mechanism. Operational procedures specify that a pilot check for two visual latched indications (green) and two visual locked indications (green) to ensure the door is fully closed. The CAS system indicates the door is fully closed when the three sensors and targets are all aligned (closed, latched, and locked). Postaccident examination found no anomalies to prevent the door from closing, latching, and locking. Door testing revealed a locked sensor assembly that was jammed due to corrosion, which resulted in a false locked door indication to the CAS when the door was actually in the latched position and not in the locked position. With the handle in the latched position, the two visual locked indications on the door were partially red, showing an accurate status of the door as not locked. Based on the findings of this accident and other similar events, Embraer released a service bulletin recommending a one-time inspection of the door locked sensor and target assembly, then subsequently added a 12-month repetitive inspection of all the sensor and target assemblies to the maintenance program.Embraer also released a flight operations letter describing in further detail the main cabin door closing procedures, as well as developed and implemented in their production line a new sensor and target assembly that mitigates the possibility for jamming.

Aircraft

Registration
N179SP
Reported as
Embraer S A EMB-545
Category
Airplane
Serial number
55010008
Airframe hours
1,678
Engines
Honeywell AS907-3-1E, 7,638 lbs thrust, turbo fanHoneywell AS907-3-1E, 7,638 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Business · Part 91
Operator
Partee Aviation LLC
Registered owner
Partee Aviation LLC
Airworthiness certificate
Standard, Transport
Last inspection
Annual · June 30, 2022
Departed
HOU · Houston, TX
Destination
BPG · Big Spring, TX
Flight plan
IFR
Equipment
Data recorder, Auto-pilot, ADS-B, Stall warning system, Onboard weather, Electronic primary flight display, Electronic multifunction display

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
71
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 24, 2022
Seat
Right
Restraint
5-point
Flight hours
24,500 total · 40 in this make and model · 16,500 as pilot in command · 15 in the last 90 days · 15 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
31
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 24, 2022
Seat
Left
Restraint
5-point
Flight hours
1,970 total · 40 in this make and model · 15 in the last 90 days · 15 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 3 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
88 °F, dew point 46 °F
Altimeter
30.02 inHg
Observed at
KHOU
METAR
KHOU 032153Z 06003KT 10SM FEW180 BKN250 31/08 A3002 RMK AO2 SLP172 T03110078

Docket · 11

The files NTSB released with the investigation on April 18, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 27.2 MB in all.

FAA reports on this event · 1

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