# NTSB NYC00LA206: Beechcraft 1900D, N858CA, Plattsburgh, NY, March 17, 2000 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 16, 2000, 21:06 local (Mar 17, 2000, 02:06 UTC) - Place: Plattsburgh, NY - Coordinates: 44.699539, -73.469856 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.6995&lon=-73.4699&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 6 uninjured - Status: Completed, report May 8, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 49793 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC00LA206 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49793/pdf - Page: https://openairdocs.org/ntsb/NYC00LA206 ## Probable cause The failure of the upper anchor bracket for the airstair door. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, standing - miscellaneous,bolt/nut/fastener/clamp/spring - failure (cause) ## 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 (not matched to a registry record) - Reported make and model: Beechcraft 1900D - Category: Airplane - Serial number: UE-72 - Engines: P&W PT6A 1279 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. - Pilot; age 41; 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 (OpenAirDocs). - [Accident 20000316008109A](https://openairdocs.org/incident/20000316008109A), Mar 16, 2000: Beech 1900D, Plattsburgh, NY, No damage. (-23) An elderly handicapped passenger, who refused assistance, fell down the stairs while boarding a/c. a BE-1900-D. The passenger was taken to the hospital,… 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.