GAA19CA372

NTSB accident investigation · Cessna T206 · Porterville, CA · April 29, 2019

Accident · No injuriesData collectionFinal report
Date
April 29, 2019, 14:01 local (21:01 UTC)
Place
Porterville, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N189JCCessna T206
Defining event
Maneuvering: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report March 20, 2020
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA
FAA report
20190429010969A
Case key
99708

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 verify that the rear cargo portion of the right cabin door was adequately secured before flight, which resulted in both portions of the door opening in flight and substantial damage to the fuselage.

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.

Doors: passenger/crew doorsAircraft › Aircraft structures · Inadequate inspectionTextron T206H: 1 caseAll aircraft: 86 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotTextron T206H: 1 caseAll aircraft: 551 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

The pilot reported that, during the preflight inspection and after a passenger had entered the airplane, he ensured that the rear cargo portion of the right cabin door, which also had a forward passenger portion adjacent to the second row of passenger seats, was secure. After completing the preflight inspection, the pilot entered the airplane and saw the passenger close and latch the forward portion of the right door. He then saw the passenger, who was seated in the right, rear passenger seat, struggling with the seatbelt, which passed between the seat and the right cargo door. The pilot suggested that the passenger switch seats, and the passenger moved to the left, rear passenger seat and fastened his seatbelt. The pilot reported that, during the flight, while maneuvering and descending to 1,600 ft mean sea level, he banked left and then heard a "brief whistle," followed by a "loud boom." He looked behind him and saw that both portions of the right cabin door were open. He returned to the departure airport without further incident. The airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane revealed red paint transfer marks on the forward portion of the door from the rear portion door latch, and both door sections could be opened if the latch for the rear door was open. The pilot reported that he believed that the right, rear passenger seatbelt "must have pulled on the [rear] door latch enough to dislodge it." He added that the red paint transfer mark was not there before the flight. The pilot provided a postaccident examination video, which showed that he was able to use the larger airbag section of the seatbelt to wedge open the rear cargo door latch. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.

Factual narrative

The pilot reported that, during preflight inspection, after a passenger had entered the airplane, he ensured that the right-rear cargo portion of the right cabin door was secure. The right side cabin door was a two-piece forward passenger door and rearward cargo door combination, and was adjacent to the second row of passenger seats. He did not close the right-front portion of the door because the passenger had secured that door multiple times before. After completing the preflight inspection, he entered the airplane and observed the passenger close and latch the forward portion of the right door. He then saw the passenger, who was seated in the right rear passenger seat struggling with the seatbelt which passed between the seat and the cargo door on the right. The pilot suggested the passenger switch seats, and the passenger moved to the left rear passenger seat and fastened his seat belt. The pilot reported that, during the flight, while maneuvering and descending to 1,600 ft mean sea level, he banked to the left and heard a "brief whistle", followed by a "loud boom sound." He looked behind him and saw both portions of the right cabin door open. He returned to the departure airport without further incident. The airplane sustained substantial damage to the fuselage. Postaccident examination revealed red paint transfer on the forward portion of the door from the rear portion door latch and that both door sections could be opened if the latch for the rear door was open. The pilot reported that he believed that the right rear passenger seat belt "must have pulled on the [rear] door latch enough to dislodge it." He added that the red paint transfer was not there before the flight. The pilot provided a postaccident examination video, which showed that he was able to use the larger airbag section of the seatbelt to wedge open the rear cargo door latch. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The "Rear Cargo Door Emergency Exit" placard in the airplane stated: 1. Open front cargo door as far as it will go. 2. Push rear door handle forward and force door open.

Aircraft

Registration
N189JC
Reported as
Cessna T206 (H)
Category
Airplane
Serial number
T20609510
Built
2017
Airframe hours
741.3
Engine
Lycoming TIO-540-AJ1A, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Public aircraft - local · Public use
Operator
Tulare County Sheriff
Registered owner
Tulare County Sheriff
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 8, 2019
Departed
PTV · Porterville, CA
Destination
PTV · Porterville, CA
Equipment
Onboard weather, Data recorder, 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
32
Injuries
None
Certificates
Commercial, Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 29, 2017
Seat
Left
Restraint
3-point
Flight hours
1,246 total · 402 in this make and model · 1,128 as pilot in command · 150 in the last 90 days · 39 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 7 knots
Visibility
10 statute miles
Lowest ceiling
4,900 ft broken
Temperature
77 °F, dew point 52 °F
Altimeter
29.77 inHg
Observed at
KPTV, 12 nm away

Docket · 4

The files NTSB released with the investigation on August 9, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.3 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.