NYC00LA206

NTSB accident investigation · Beechcraft 1900D · Plattsburgh, NY · March 17, 2000

Accident · Serious injuriesLimited investigationFinal report
Date
March 16, 2000, 21:06 local (Mar 17, 2000, 02:06 UTC)
Place
Plattsburgh, NY
Injuries
1 serious, 6 uninjured
Damage
No damage
Phase of flight
Standing
Aircraft
N858CABeechcraft 1900D
Weather
Instrument (IMC) · Night/dark
Status
Completed · report May 8, 2001
Report
Approved by Office Director
FAA report
20000316008109A
Case key
49793

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 failure of the upper anchor bracket for the airstair door.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionStanding
Miscellaneous,bolt/nut/fastener/clamp/spring - failureCause

Analysis

All passengers except one had disembarked from the airplane. As the last passenger approached the first step of the airstairs, he 'lost his balance,' and reached for the right side guide cable. The top anchor bracket of the guide cable became disconnected and the passenger fell down the stairs, striking the pavement with his right side. The anchor bracket was manufactured from an aluminum casting. Five months after the accident, a service bulletin was issued which addressed replacement of the upper anchor brackets for the airstair door forward and aft handrail cables. The replacement was required due to reports of separations of the upper anchor brackets. The bulletin also stated, 'Separation of these handrail cable upper anchor brackets can result in the airstair door becoming unstable in addition to loss of handrail support for crew, maintenance personnel or passengers when using the handrail.' The new upper anchor bracket was an improved design machined from steel alloy.

Factual narrative

On March 16, 2000, at 2106 Eastern Standard Time, a passenger was seriously injured when he fell down the stairs of a Beechcraft 1900D, N858CA, operated as CommutAir flight 4480, at the Clinton County Airport (PLB), Plattsburgh, New York. The airplane was not damaged. The captain, first officer, and three additional passengers were not injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan had been filed for the scheduled passenger flight that departed Burlington International Airport (BTV), Burlington, Vermont, at 2015. The flight was conducted under 14 CFR Part 121.

According to a written statement from the operator, the flight landed at 2103, and all passengers except one disembarked from the airplane. The last passenger "only had the use of his right arm," and was offered assistance by the first officer to exit the airplane. The passenger refused the assistance, and as he approached the first step of the airstairs, he "lost his balance," and reached for the right side guide cable. The top anchor of the guide cable became disconnected and the passenger fell down the stairs, striking the pavement with his right side.

The passenger was transported to a local hospital where he succumbed to his injuries on June 10, 2000.

According to a Federal Aviation Administration inspector, the anchor that attached the upper forward cable to the doorframe became disconnected as the passenger proceeded down the airstairs. The anchor bracket, (P/N 50-440037-13), was manufactured from an aluminum casting. The operator, who had problems with the brackets on other airplanes, began to replace the anchor brackets with ones comprised of a stronger material. The accident airplane was due for maintenance in the future, and at that time, the replacement bracket would have been installed.

According to the airplane manufacturer, a service bulletin was issued in November 2000, which addressed replacement of the upper anchor brackets for the airstair door forward and aft handrail cables. The replacement was required due to reports of separations of the upper anchor brackets. The bulletin also stated, "Separation of these handrail cable upper anchor brackets can result in the airstair door becoming unstable in addition to loss of handrail support for crew, maintenance personnel or passengers when using the handrail."

The new upper anchor bracket (P/N 129-440077-1) was an improved design machined from steel alloy.

Aircraft

Registration
N858CA
Reported as
Beechcraft 1900D
Category
Airplane
Serial number
UE-72
Engine
P&W PT6A, 1,279 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Registered owner
Champlain Enterprises Inc
Airworthiness certificate
Standard, Transport
Departed
BTU · Burlington, VT
Destination
PLB
Flight plan
IFR
Airport
PLB · Clinton County Airport

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
30° at 6 knots
Visibility
1.5 statute miles
Lowest ceiling
900 ft overcast
Temperature
25 °F, dew point 25 °F
Altimeter
30.00 inHg
Observed at
PLB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.