ERA10IA285

NTSB incident investigation · Cessna 560XL · White Plains, NY · May 28, 2010

Incident · No injuriesIncident investigationFinal report
Date
May 28, 2010, 12:20 local (16:20 UTC)
Place
White Plains, NY
Injuries
4 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N662QSCessna 560XL
Defining event
Approach-VFR pattern downwind: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report November 17, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
NetJets Association of Shared Aircraft Pilots, Netjets Aviation Inc., FAA/FSDO
FAA report
20100528054029I
Case key
76144

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The flight crew's failure to ensure that the cabin door was secured/locked prior to takeoff.

Findings · 2

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.

Inspection: preflight inspectionPersonnel issues › Task performance · Flight crewAll aircraft: 551 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

After concluding the preflight safety briefing for the passengers, the first officer closed the cabin door. The first officer remembered rotating the door locking handle but could not recall the direction he rotated it. He also could not recall looking at the cabin door lock indicator lights or the cockpit indicator, as was required by the operator's preflight checklist. Just after takeoff, the captain recalled that he heard the cabin door "leaking" and the first officer observed that the DOOR SEAL/CABIN DOOR annunciator lights were illuminated. When asked, the first officer did not recall the MASTER CAUTION annunciator illuminating. Had the MASTER CAUTION annunciator illuminated, it would have been one indication that the door was properly secured prior to the takeoff. While on the downwind leg of the traffic pattern during the return for landing, the main cabin door opened. The crew subsequently declared an emergency, and landed uneventfully with the main cabin door open. The airplane incurred minor damage during the landing and the passengers and crew were not injured. Postincident examination of the door and its locking and indicating mechanisms revealed no evidence of any mechanical malfunctions or failures. Because of the close proximity of the amber-colored CABIN DOOR annunciator light and the white-colored GROUND IDLE annunciator light, it is possible that the flight crew inadvertently overlooked the illuminated CABIN DOOR annunciator light prior to takeoff.

Factual narrative

HISTORY OF FLIGHT On May 28, 2010, about 1220 eastern daylight time, a Cessna 560XL, N662QS, incurred minor damage when the main cabin door opened while in flight, shortly after takeoff from Westchester County Airport (HPN), White Plains, New York. The certificated airline transport pilot-rated captain, first officer, and the two passengers were not injured. Visual meteorological conditions prevailed, and the flight was operating on an instrument flight rules flight plan. The corporate flight was destined for Nantucket Memorial Airport (ACK), Nantucket, Massachusetts. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91K. The captain and first officer were interviewed separately by Federal Aviation Administration inspectors following the incident. Both pilots were qualified to act as captains in the Cessna 560XL, and their roles for the incident flight were previously defined by the operator. The captain was also designated as the pilot flying, while the first officer was designated as the pilot not flying (or pilot monitoring). During his safety briefing with the passengers after boarding, the first officer closed the cabin door. The first officer remembered rotating the door locking handle, but could not recall the direction he rotated it. He also could not recall looking at the door post locking indicator lights or the cockpit indicator. After completing the required checklists, the crew taxied the airplane "slowly" toward runway 16, and was delayed before being cleared to depart. During the delay, the captain focused his attention on the air traffic control communications and formulated a mental picture of the traffic in the area of the airport. Just after takeoff, the captain recalled that he heard the cabin door leaking and the first officer observed that the DOOR SEAL/CABIN DOOR annunciator light was illuminated. When asked, the first officer did not recall the master caution annunciator illuminating. The crew requested and was cleared to return to runway 16. While on the downwind leg of the traffic pattern, the main cabin door opened. The crew subsequently declared an emergency, and landed uneventfully with the main cabin door open. AIRCRAFT INFORMATION According to the Cessna 560XL maintenance manual, the cabin door was located on the left forward side of the airplane. The door was hinged at its bottom, opened outward, and was equipped with a pre-catch mechanism, which assisted in holding the door closed before the locking mechanism was engaged. Eight locking pins were mechanically linked to internal and external lock/unlock handles, with three locking pins located in each side of the door and two locking pins at the top of the door. When actuated by the lock/unlock handle, the door pins extended into the door frame sockets to secure the door in the closed position. Six electrical switches monitored the door's closed and locked position, with four switches actuated by the upper and lower sidelocking pins, one switch monitoring the door vent, and one switch monitoring the door locking mechanism's position. The switches were electrically connected to the warning annunciator panel in the cockpit, and only when each of the six switches was closed, would the CABIN DOOR annunciator extinguish. Should any of the six switches toggle from locked to unlocked, the CABIN DOOR and MASTER CAUTION annunciator would illuminate. Resetting the MASTER CAUTION would extinguish the MASTER CAUTION annunciator, but the CABIN DOOR annunciator would remain illuminated. A DOOR LOCKS panel was also located on the cabin door post, and was equipped with six light-emitting diodes to indicate the position of the door locks, door handle, and vent door. Each light illuminated when its respective switch sensed that a component was in the unlocked position and extinguished when its respective component was in the locked or closed position. When the door was closed and locked, the door vent light extinguished after several seconds and the vibration from the closing vent could be felt near the bottom of the cabin door. Additionally, nine indicator windows were placed throughout the door, so that when the door was properly closed and locked, a phosphorescent green flag was clearly visible through each respective indicating window. The cockpit annunciator panel provided numerous system notifications to the crew. The CABIN DOOR annunciator light (colored yellow) was located on the bottom of three rows of annunciator lights, on the sixth column from the right. The GROUND IDLE annunciator light (colored white) was also located on the sixth column from the right, above the CABIN DOOR annunciator light, on the first row of annunciator lights. The GROUND IDLE annunciator would normally be illuminated after engine start and while the airplane was taxiing to the runway, and would be the only annunciator illuminated just prior to takeoff. PERSONNEL INFORMATION The captain held an airline transport pilot certificate with ratings for airplane single and multi-engine land. The pilot's most recent first-class medical certificate was issued in July 2009. He reported 7,459 total hours of flight experience, 1,737 hours of which were in the incident airplane make and model. The first officer held an airline transport pilot certificate with ratings for airplane single and multi-engine land. His most recent first-class medical certificate was issued in April 2010. He reported 5,964 total hours of flight experience, 1,432 hours of which were in the incident airplane make and model. METEOROLOGICAL INFORMATION At 1156 recorded weather at HPN included calm winds, a broken ceiling at 3,200 feet, 10 statute miles visibility, temperature 19 degrees C, dew point 11 degrees C, and an altimeter setting of 29.98 inches of mercury. FLIGHT RECORDERS The airplane was equipped with a cockpit voice recorder, which was retained and auditioned in the NTSB Vehicle Recorders Laboratory. Audition of therecorder revealed a series of events consistent with the flight crews' statements. While completing the engine start checklist, the crew noted 'cabin door closed' and 'lights out'. Shortly thereafter, the flight crew noted that the annunciators and instruments were checked. The flight crew completed the runway items checklist and noted "lights, heat, and lights out." TESTS AND RESEARCH Two FAA inspectors examined the main cabin door after the incident. According to the inspectors, the door had been over-extended when it opened in-flight, and had scraped against the runway during the landing. Damage to the door precluded closing the door normally, though the door could be opened and closed with force provided by individuals on the inside and outside. Detailed mechanical inspection of the door revealed that the pre-catch mechanism appeared to operate normally, and there was no visual indication of any door locking pin or pin socket failure. The annunciator lights on the DOOR LOCK panel and the CABIN DOOR annunciator functioned normally, including illumination of the MASTER CAUTION annunciator when the door was opened. The inspectors further noted that if electrical power (from a the airplane's battery or a power cart) was applied to the airplane with the cabin door open, the CABIN DOOR annunciator remained steadily illuminated until the door was closed. The illumination of a MASTER CAUTION annunciator, accompanied by a blinking CABIN DOOR annunciator, would only occur after the door was closed, locked, then unlocked and reopened. ADDITIONAL INFORMATION According to the operator's Expanded Normal Procedures, Engine Start checklist, both of the pilots were to perform the following actions: Cabin Door.................Closed/Light Out -Close and latch cabin door -Verify cabin door pin indicators are visible -Verify cabin door red LED lights are extinguished -Verify the cockpit Cabin Door annunciator is extinguished. The Runway Items flow checklist procedure required the pilot monitoring to ensure that all annunciator lights were extinguished with the exception of GROUND IDLE after being cleared for takeoff.

Aircraft

Registration
N662QS
Reported as
Cessna 560XL
Category
Airplane
Serial number
5605262
Airframe hours
7,384
Engines
P&W Canada PW545 SER, 3,952 lbs thrust, turbo fanP&W Canada PW545 SER, 3,952 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 91 subpart K
Registered owner
Netjets Sales Inc
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · March 22, 2010
Departed
HPN · White Plains, NY
Destination
ACK · Nantucket, MA
Flight plan
IFR
Airport
HPN · Westchester County Airport, runway 16, 6,548 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 31, 2010
Seat
Left
Flight hours
7,459 total · 1,737 in this make and model · 126 in the last 90 days · 35 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
47
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 26, 2010
Seat
Right
Flight hours
5,964 total · 1,432 in this make and model · 84 in the last 90 days · 22 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
3,200 ft overcast
Temperature
66 °F, dew point 52 °F
Altimeter
29.97 inHg
Observed at
HPN

Docket · 9

The files NTSB released with the investigation on September 28, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.5 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.