# NTSB CEN23LA003: Embraer S A EMB-545, N179SP, Houston, TX, October 3, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 3, 2022, 17:40 local (22:40 UTC) - Place: Houston, TX - Coordinates: 29.6455, -95.278432 - Nearby events: https://openairdocs.org/map.md?lat=29.6455&lon=-95.2784&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 4 uninjured - 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 - NTSB case key (mKey): 106055 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA003 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106055/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106055 - Page: https://openairdocs.org/ntsb/CEN23LA003 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Copilot (probable cause); cases with it: [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Indicating/recording systems](https://openairdocs.org/ntsb-findings/01023100): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01023100/cases.md) - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Incorrect use/operation (probable cause); cases with it: [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01035210/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: EMBRAER S A EMB-545 - Category: Airplane - Serial number: 55010008 - Airframe hours: 1678 - Engines: Honeywell AS907-3-1E 7638 lbs thrust turbo fan; Honeywell AS907-3-1E 7638 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 As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: minor; 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 - Co-pilot; age 31; injuries: none; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20221003021659A](https://openairdocs.org/incident/20221003021659A), Oct 3, 2022: Embraer S A EMB-545, Houston, TX, Substantial damage. The Houston flight standards district office received a report indicating that aircraft [privacy data omitted], an Embraer 545 model, returned to William p.… ## Docket (11 files) The files NTSB released with the investigation on April 18, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106055. 27.2 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16004862&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Photo array (item 2, PDF, 3 pages, 467 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16005275&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Previous door seal repair (item 3, PDF, 5 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16493030&FileExtension=pdf&FileName=Embraer%20Door%20Repair_Redacted-Rel.pdf - Damage assessment information (item 4, PDF, 1 page, 348 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16526312&FileExtension=pdf&FileName=Substantial%20damage_Redacted-Rel.pdf - Flight data recorder - specialist's factual report (item 5, PDF, 17 pages, 10 photos, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16074244&FileExtension=pdf&FileName=CEN23LA003%20-%20FDR%20-%20FINAL-Rel.pdf - Flight data recorder - attachment 1 (csv data for accident flight) (item 6, CSV, 9.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16074254&FileExtension=csv&FileName=CEN23LA003_FINAL_CSV-Rel.csv - Structures group chair's factual report (item 7, PDF, 14 pages, 8 photos, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16440083&FileExtension=pdf&FileName=CEN23LA003%20Structures%20Factual-Rel.pdf - Structures attachment 1 - Embraer legacy main entry door (item 8, PDF, 8 pages, 675 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16439692&FileExtension=pdf&FileName=CEN23LA003%20Structures%20Att1-MED-Rel.pdf - Structures attachment 2 - Embraer service information (item 9, PDF, 56 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16439981&FileExtension=PDF&FileName=CEN23LA003%20Structures%20Att2-Service%20Info-Rel.PDF - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 2 pages, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16526548&FileExtension=pdf&FileName=Wreckage%20Release%20Form_Redacted-Rel.pdf - Cockpit voice recorder - specialist's factual report (item 11, PDF, 8 pages, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16942499&FileExtension=pdf&FileName=CEN23LA003%20-%20CVR%20-%20DOCKET-Rel.pdf 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.