# NTSB NYC92IA030: Douglas DC-8-63, N794AL, Toledo, OH, November 13, 1991

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: November 13, 1991, 04:45 local (09:45 UTC)
- Place: Toledo, OH
- Coordinates: 41.58052, -83.889221 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.5805&lon=-83.8892&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report May 5, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 37078
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC92IA030
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37078/pdf
- Page: https://openairdocs.org/ntsb/NYC92IA030

## Probable cause

THE FAILURE OF THE FLIGHT ENGINEER TO CONDUCT A PROPER PREFLIGHT INSPECTION AND ENSURE THE MAIN CARGO DOOR WAS FULLY CLOSED AND LOCKED. FACTORS RELATED TO THE ACCIDENT WERE THE DAMAGED WIRES IN THE BUNDLE, AND THE IMPROPER MAIN CARGO DOOR INSTALLATION.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Decompression, climb - to cruise
  - door,cargo/baggage - improper (contributing factor)
  - maintenance,installation - improper, other maintenance personnel (contributing factor)
  - electrical system,electric wiring - chafed (contributing factor)
  - aircraft preflight - improper, flight engineer (cause)

## Analysis

THE MAIN CARGO DOOR OPENED IN FLIGHT AND THE AIRPLANE RETURNED FOR A NORMAL LANDING.  OF THE TWO CIRCUIT BREAKERS REQUIRED TO BE PULLED PRIOR TO TAKEOFF, ONE WAS FOUND STILL ENGAGED.  A CONFORMITY INSPECTION ON THE CARGO DOOR INSTALLATION REVEALED SEVERAL AREAS OF NONCONFORMITY INCLUDING DOOR LOCKS OF LESS THAN REQUIRED STRENGTH, LACK OF PAINT ON DOOR LOCKS WHICH IS USED FOR VISUAL IDENTIFICATION, AND DAMAGED WIRES IN A BUNDLE. THE WIRES WERE PART OF THE DOOR CLOSING, DOOR LOCKED INDICATING SYSTEM. THE INVESTIGATION REVEALED IT WAS POSSIBLE FOR THE DOOR TO BE NOT COMPLETELY CLOSED AND HAVE THE DOOR WARNING LIGHT GO OUT, INDICATING IT WAS FULLY LOCKED.

## Aircraft

- Registration: [N794AL](https://openairdocs.org/deregistered/N794AL-1993-03-29), registration cancelled 1993-03-29, S/N 45923 (OpenAirDocs)
- Reported make and model: DOUGLAS DC-8-63
- Category: Airplane
- Serial number: 45923
- Engines: P&W JT3D-7 19000 lbs thrust turbo fan
- Damage: Minor damage
- Flight: Part 121
- Operator: Flagship Express
- Registered owner: Aero Lease Financial Group Inc
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, January 2, 2000
- Destination: LAX, LOS ANGELES, CA
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 33; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 8,000 total, 6,300 in this make and model

## Weather

- Conditions: Visual (VMC), Night/dark

## Other investigations on N794AL (1)

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.

- [NTSB DCA92MA022](https://openairdocs.org/ntsb/DCA92MA022), Feb 15, 1992: Douglas DC-8-63 (N794AL), Swanton, OH, destroyed, 4 fatal. Probable cause: THE FAILURE OF THE FLIGHTCREW TO PROPERLY RECOGNIZE OR RECOVER IN A TIMELY MANNER FROM THE UNUSUAL AIRCRAFT ATTITUDE THAT RESULTED FROM THE CAPTAIN'S APPARENT SPATIAL DISORIENTATION, RESULTING FROM…

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.

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