CHI96LA025

NTSB accident investigation · Beech A90 · Wichita, KS · November 3, 1995

Accident · No injuriesLimited investigationFinal report
Date
November 3, 1995, 15:00 local (21:00 UTC)
Place
Wichita, KS
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N93RYBeech A90
Weather
Visual (VMC) · Day
Status
Completed · report April 18, 1996
Report
Approved by Office Director
FAA report
19951103036059A
Case key
10147

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

failure of the pilot to follow procedures/directives regarding the entrance door, which resulted the door coming open in flight.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Miscellaneous/otherCruise
Door,entrance stair - leak
Procedures/directives - not followedPilot in commandCause
Door,entrance stair - openCause
DecompressionCruise

Analysis

While on a maintenance test flight at 14,500 feet, the pilot went back to check the cabin door for air leaks. He noticed a whistling noise and decided to troubleshoot. He pushed the cabin door button followed by turning the handle from the neutral to the locked position, then began pushing on the cabin door. At this point, the door opened in-flight. An on-scene investigation revealed no anomalies with the cabin door. The pilot did not observe the caution placard on the door nor the emergency door warning notice in the flight manual.

Factual narrative

On November 3, 1995, at 1500 central standard time, a Beech A90, N93RY, registered to Ryan Aviation Corporation, of Wichita, Kansas, was substantially damaged when the air-stair door opened in-flight. The airline transport pilot, copilot and passenger reported no injuries. The maintenance check 14 CFR Part 91 flight was operating in visual meteorological conditions. No flight plan was on file. The flight departed Wichita, Kansas, at 1445.

Before takeoff the pilot-in-command (PIC) said he closed the main cabin door and did a six point check on the door. The check involved ensuring the door's four bayonet pins and two plungers were in the locked position. He said all six items were in the locked position. During cruise flight the airplane was at a maximum cabin presssure of 4.6 psi. The PIC stated he was performing a maintenance check flight on a newly installed door seal at 14,500 feet. The PIC went back to check the door for air leaks. He said he noticed air leaking and a whistling noise coming from the door. He then decided to trouble shoot by pushing the cabin door lock/unlock button, followed by moving the door handle from the "neutral" position to the locked position. The noise continued and he than began pushing on the door; at this point the door released in-flight.

A Federal Aviation Administration Principal Maintenance Inspector represented the NTSB during the on-scene investigation. The investigation revealed no anomalies with the cabin door. All bayonet pins extended to the distance stated in the maintenance manual when the handle is in the locked position.

A placard adjacent to the cabin door handle stated, "CAUTION DO NOT ATTEMPT TO CHECK SECURITY OF CABIN DOOR BY MOVING DOOR HANDLE UNLESS CABIN IS DEPRESSURIZED AND AIRCRAFT IS ON THE GROUND." The pilot's operating handbook emergency section concerning illumination of cabin door warning light procedures states, "WARNING the cabin door handle latching mechanism is an over-centering mechanism and must be in the over-center position to be fully latched, as indicated by the arm and plunger. If cabin is pressurized and door is not completely latched, any movement of the door handle toward the unlocked position may cause rapid and complete unlatching and opening of the door due to forces created by the two upper door hooks."

Aircraft

Registration
N93RY
Reported as
Beech A90
Category
Airplane
Serial number
LJ-174
Airframe hours
13,040
Engine
P&W PT6A-20, 550 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 91
Registered owner
Ryan Aviation Corporation
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 13, 1995 · 35 hours before
Departed
3KM
Airport
3KM · Colonel James Jabara

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
6,500 total · 2,500 in this make and model · 6,000 as pilot in command · 150 in the last 90 days · 50 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 12 °F
Altimeter
30.00 inHg
Observed at
ICT

FAA reports on this event · 1

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