# NTSB MIA00IA164: Beech 1900C, N154GA, Fort Lauderdale, FL, May 19, 2000 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: May 19, 2000, 14:54 local (18:54 UTC) - Place: Fort Lauderdale, FL - Coordinates: 26.08941, -80.149589 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.0894&lon=-80.1496&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 22 uninjured - Status: Completed, report April 20, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 49241 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA00IA164 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49241/pdf - Page: https://openairdocs.org/ntsb/MIA00IA164 ## Probable cause The failure of the first officer to comply with procedures and directives for his failure to assure that the forward airstair door was closed and locked. A contributing factor in the incident was the inoperative annunciation system of the forward airstair door. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, climb - to cruise - annunciator panel light(s) - inoperative (contributing factor) - door,entrance stair - open - procedures/directives - not complied with, copilot/second pilot (cause) ## Analysis The 'fwd cabin door' annunciator light was inoperative and MEL'd; it was scheduled to be examined later that evening. Six discrepancies in the previous year pertaining to the forward airstair door annunciator were recorded; the latest discrepancy was 2 days earlier. The captain briefed the MEL item with the first officer (F/O), who reported closing and locking the forward airstair door, and verifying such. The F/O reported only verbally briefing the passenger adjacent to the door about the door opening procedures but did not demonstrate. After takeoff at 800 feet 800 feet msl, the forward airstair door opened. An emergency was declared, the flight returned and landed uneventfully. The propeller blades and aft cables of the forward airstair door were damaged; the door latching mechanism operated normally. The company F/O's are taught to verbally discuss with passengers the door opening procedure without demonstrating. Several of the company F/O's reported partially opening the forward airstair door to demonstrate the procedure to the passenger; accomplishing this after closing and locking the door. Post incident, the F/O was vague about how to verify that the forward airstair door is locked. The results of drug screening of the captain and FO were negative. ## Factual narrative On May 19, 2000, about 1454 eastern daylight time, a Beech 1900C, N154GA, registered to Raytheon Aircraft Receivables Corporation, operated by Gulfstream International Airlines, Inc., as flight 9204, experienced opening of the forward airstair door shortly after takeoff from the Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 121, scheduled, international, passenger flight. The airplane sustained minor damage and there were no reported injuries to the airline transport-rated captain, commercial-rated first officer, or 20 passengers. The flight originated at 1452, from the Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida. The captain stated that before departure he reviewed the aircraft flight log and noted that the cabin door warning light was "mel'd". He discussed this with the first officer (F/O) who performed a preflight of the airplane. The F/O reported that after the passengers were boarded, he closed and latched the forward airstair door and verified that it was closed by viewing inside the inspection window and also by viewing the cam sight gauges. He also briefed the passenger in seat 1A, about the emergency procedures pertaining to the door. The captain reported that the flight taxied to runway 9L, was cleared to takeoff, and while climbing through 800 feet mean sea level, he "heard a slight explosion (decompression) and found the forward cabin door [had] blown open." He declared an emergency, returned to Fort Lauderdale, and landed uneventfully. After taxiing to the ramp, he shut down the engines normally and was not aware of damage to the left propeller until after securing the left engine. Postincident examination of the left propeller revealed a gouge in the leading edge of one of the blades and segments of the blade tips of two of the blades were noted to be missing; damage to all four propeller blades was noted. Examination of the forward airstair door revealed that the aft cable assembly was broken and missing an approximate 27-inch segment; several holes were noted in the outer door skin. The door latching mechanism was found to operate normally; no discrepancies were noted. For a period of 1 year from the date of the incident, there were six discrepancies pertaining to annunciation of the forward airstair door. Corrective action was accomplished on all six discrepancies; all were signed off as being operationally checked normal or "OK." On May 8, 2000, the airplane was released in accordance with minimum equipment list (MEL) pertaining to the discrepancy that the forward cabin door annunciator extinguishes without locking the handle; the discrepancy was corrected on May 15, 2000. The same discrepancy of May 8th, was written up again on May 16th; the airplane was again released in accordance with minimum equipment list (MEL). The forward airstair door annunciator remained inoperative for the incident flight and was scheduled to be examined on the evening of the incident date. According to the airline Vice President/Director of Flight Operations (VP/DFO), post incident, the F/O was vague about how to verify that the forward airstair door is locked; he was immediately removed from the flight line and received additional training. He also stated that he interviewed six company F/O's and three of the six reported they would partially open the forward airstair door to demonstrate to the passenger seated in row 1A how to open the door. This would be performed after each F/O verified that the forward airstair door was closed and locked. The VP/DFO reported that the incident F/O stated to him that he did not touch the door but recalled verbally describing the procedure to the passenger sitting in row 1A. The VP/DFO also reported that the company F/O's are taught to verbally describe the door opening procedure to the passenger without operating the door. Post incident, the captain and first officer submitted samples in accordance with the FAA approved drug testing program; both were negative for tested drugs of abuse. ## Aircraft - Registration: [N154GA](https://openairdocs.org/aircraft/N154GA), registered now, S/N UB-25, built 1984 (OpenAirDocs) - Reported make and model: Beech 1900C - Registry model: [Beech 1900C](https://openairdocs.org/model/beech-1900c) (registry code 1154161) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: UB25 - Airframe hours: 29037 - Engines: P&W PT6A-65B 1100 horsepower turbo prop - Damage: Minor damage - Flight: Part 121 - Operator: Gulfstream International, doing business as Continental Connection - Registered owner: Raytheon Aircraft Receivables - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, May 1, 2000, 116 hours before - Departed: FLL - Destination: MYGF, FREEPORT, OF - Flight plan: IFR - Airport: FLL, Fort Lauderdale/Hollywood ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; private, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 2,800 total, 100 in this make and model, 2,000 as pilot in command, 100 in the last 90 days, 100 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 3,600 ft broken - Temperature: 82 °F, dew point 64 °F - Altimeter: 30.00 inHg - Observed at: FLL ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20000519017729I](https://openairdocs.org/incident/20000519017729I), May 19, 2000: Beech 1900C, Ft Lauderdale, FL, Minor damage. (-23)After an interview with the first officer, it appears that during the passenger briefing, the first officer may have moved the airstair door handle up,… 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.