ERA20CA100

NTSB accident investigation · Cessna 402 · Barnstable, MA · February 12, 2020

Accident · No injuriesData collectionFinal report
Date
February 12, 2020, 14:12 local (19:12 UTC)
Place
Barnstable, MA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N409BKCessna 402
Defining event
Initial climb: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report August 25, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
100939

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 pilot's failure to properly secure the crew hatch door before takeoff, which resulted in the door’s forward hinge assembly tearing from its fuselage mount point.

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.

Windows-windshield system: flight compartment windowsAircraft › Aircraft structures · Incorrect use/operationCessna 402C: 1 caseAll aircraft: 42 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 402C: 3 casesAll aircraft: 1,391 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

According to the operator, during initial climb, the door warning light illuminated, and the crew hatch door opened. The door's forward hinge assembly was then torn from its fuselage mount point along with adjacent aircraft skin, which resulted in substantial damage to the airplane. Postaccident examination of the airplane revealed that the door safety latch, warning system, and door latching mechanism worked properly. The operator reported that it was possible to latch the door with the forward pin in its proper anchor point and with the aft pin outside the airframe with the warning light extinguished. The operator further reported that, after the accident, this was covered in aircrew training and the company standard operating procedures.

Factual narrative

According to the operator, the airplane was on its initial climb when the door warning light illuminated, and the crew hatch door opened. The door then tore the forward hinge from its mount along with the adjacent aircraft skin, which resulted in substantial damage to the airplane. Postaccident examination of the airplane confirmed proper operation of the door safety latch, warning system, and door latching mechanism. The operator explained that it was possible to latch the door with the forward pin in its proper anchor point, and with the aft pin outside the airframe, yet still extinguish the warning light. The operator further reported that this was covered in aircrew training as well as the company standard operating procedures.

Aircraft

Registration
N409BK
Reported as
Cessna 402 (C)
Category
Airplane
Serial number
402C0651
Built
1982
Airframe hours
28,493
Engines
Continental TSIO-520 SER, 325 horsepower, reciprocatingContinental TSIO-520 SER, 325 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Hyannis Air Service Inc Dba
Registered owner
Hyannis Air Service Inc Dba
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 15, 2020 · 40 hours before
Departed
HYA · Barnstable, MA
Destination
HYA · Barnstable, MA
Flight plan
VFR
Airport
HYA · Barnstable Muni-Boardman/Polan, runway 24, 5,425 × 150 ft, asphalt
Equipment
Onboard weather, Auto-pilot, ADS-B, Stall warning system

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
52
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
10,786 total · 2,752 in this make and model · 9,215 as pilot in command · 103 in the last 90 days · 32 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 20 knots, gusting 27
Visibility
10 statute miles
Temperature
39 °F, dew point 10 °F
Altimeter
30.09 inHg
Observed at
HYA

Docket · 2

The files NTSB released with the investigation on May 7, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.6 MB in all.