# NTSB ERA20CA100: Cessna 402, N409BK, Barnstable, MA, February 12, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: February 12, 2020, 14:12 local (19:12 UTC) - Place: Barnstable, MA - Coordinates: 41.669166, -70.280281 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.6692&lon=-70.2803&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: 1 uninjured - Status: Completed, report August 25, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 100939 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20CA100 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100939/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100939 - Page: https://openairdocs.org/ntsb/ERA20CA100 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Windows-windshield system: flight compartment windows](https://openairdocs.org/ntsb-findings/01035610): Aircraft › Aircraft structures · Incorrect use/operation (probable cause); cases with it: [Cessna 402C, 1 case](https://openairdocs.org/ntsb-findings/01035610/cases.md?model=207590R), [All aircraft, 42 cases](https://openairdocs.org/ntsb-findings/01035610/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: [Cessna 402C, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=207590R), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cessna 402C, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=207590R), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna 402C, 8 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=207590R), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) ## 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](https://openairdocs.org/aircraft/N409BK), registered now, S/N 402C0651, built 1982 (OpenAirDocs) - Reported make and model: Cessna 402 (C) - Registry model: [Cessna 402C](https://openairdocs.org/model/cessna-402c) (registry code 207590R) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402C0651 - Year built: 1982 - Airframe hours: 28493 - Engines: Continental TSIO-520 SER 325 horsepower reciprocating; Continental 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; 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 files) The files NTSB released with the investigation on May 7, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100939. 5.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483520&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo Array (item 2, .PDF, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483521&FileExtension=.PDF&FileName=Photo%20Array-Master.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.