# NTSB CHI96LA025: Beech A90, N93RY, Wichita, KS, November 3, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 3, 1995, 15:00 local (21:00 UTC) - Place: Wichita, KS - Coordinates: 37.769847, -97.210983 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.7698&lon=-97.2110&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report April 18, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 10147 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI96LA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10147/pdf - Page: https://openairdocs.org/ntsb/CHI96LA025 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, cruise - door,entrance stair - leak - procedures/directives - not followed, pilot in command (cause) - door,entrance stair - open (cause) - Decompression, cruise ## 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](https://openairdocs.org/deregistered/N93RY-2013-02-07), registration cancelled 2013-02-07, S/N LJ-174, built 1966 (OpenAirDocs) - Reported make and model: BEECH A90 - Registry model: [Beech 65-A90](https://openairdocs.org/model/beech-65-a90) (registry code 1152908) (OpenAirDocs) - Registry engine: [U/A Canada PT6 SER 578HP](https://openairdocs.org/engine/u-a-canada-pt6-ser-578hp) (registry code 61501, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: LJ-174 - Airframe hours: 13040 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; 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 (OpenAirDocs). - [Accident 19951103036059A](https://openairdocs.org/incident/19951103036059A), Nov 3, 1995: Beech 65A90, Wichita, KS, Substantial damage. Airstair opened during test flight for new door seal. Disregard placard not to unlock door inflight. Checking 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. --- 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.