# NTSB GAA19CA372: Cessna T206, N189JC, Porterville, CA, April 29, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: April 29, 2019, 14:01 local (21:01 UTC) - Place: Porterville, CA - Coordinates: 35.927223, -119.271942 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.9272&lon=-119.2719&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 20, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99708 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA372 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99708/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99708 - Page: https://openairdocs.org/ntsb/GAA19CA372 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Inadequate inspection (probable cause); cases with it: [Textron T206H, 1 case](https://openairdocs.org/ntsb-findings/01035210/cases.md?model=2073343), [All aircraft, 86 cases](https://openairdocs.org/ntsb-findings/01035210/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Textron T206H, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2073343), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/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: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Textron T206H, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=2073343), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Maneuvering: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Textron T206H, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=2073343), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## 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](https://openairdocs.org/aircraft/N189JC), registered now, S/N T20609510, built 2017 (OpenAirDocs) - Reported make and model: Cessna T206 (H) - Registry model: [Textron T206H](https://openairdocs.org/model/textron-t206h) (registry code 2073343) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AJ1A](https://openairdocs.org/engine/lycoming-tio-540-aj1a) (registry code 42004, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: T20609510 - Year built: 2017 - Airframe hours: 741.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; 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 ## 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 20190429010969A](https://openairdocs.org/incident/20190429010969A), Apr 29, 2019: Textron Aviation Inc T206H, Porterville, CA, Substantial damage. During flight, the right side rear pax/baggage door opened in flight, striking the right rear side of the aircraft fuselage, causing substantial damage to the… ## Docket (4 files) The files NTSB released with the investigation on August 9, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99708. 4.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475000&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475001&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Seat Belt Unlatch Video (item 3, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475002&FileExtension=.PDF&FileName=Seat%20Belt%20Unlatch%20Video-Master.PDF - Accident Photos (item 4, .PDF, 380 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475003&FileExtension=.PDF&FileName=Accident%20Photos-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.