# NTSB SEA08IA096: Raytheon 1900D, N261GL, Page, AZ, March 26, 2008 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: March 26, 2008, 12:20 local (19:20 UTC) - Place: Page, AZ - Coordinates: 36.925834, -111.448333 - Nearby events: https://openairdocs.org/map.md?lat=36.9258&lon=-111.4483&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 13 uninjured - Status: Completed, report December 24, 2008 - Report: Approved by Office Director - Parties: Federal Aviation Administration AAI-100, Federal Aviation Administration, Great Lakes Airlines, Inc. - NTSB case key (mKey): 67723 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA08IA096 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67723/pdf - Page: https://openairdocs.org/ntsb/SEA08IA096 ## Probable cause The flight crew’s unprofessional behavior and deviation from standard operating procedures which resulted in an in-flight emergency. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Culture](https://openairdocs.org/ntsb-findings/04024000): Organizational issues › Management · Operator; cases with it: [Raytheon 1900D, 1 case](https://openairdocs.org/ntsb-findings/04024000/cases.md?model=7150005), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/04024000/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Raytheon 1900D, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7150005), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Flight crew; cases with it: [Raytheon 1900D, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7150005), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Culture: standard operating practices](https://openairdocs.org/ntsb-findings/04024015): Organizational issues › Management · Not specified (probable cause); cases with it: [Raytheon 1900D, 1 case](https://openairdocs.org/ntsb-findings/04024015/cases.md?model=7150005), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/04024015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Raytheon 1900D, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=7150005), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## Analysis The scheduled air carrier was departing from an airport. During taxi, cockpit voice recorder data indicated that the first officer was stating and verifying the checklists, as well as taxiing the airplane. Company standard operating procedures required that those checklists be called out by one crewmember and verified by the other. The flight crew spoke of personal matters and did not follow the sterile cockpit regulations as specified by 14 Code of Federal Regulations Part 21.542. The captain stated that during takeoff, the cargo door light illuminated, the aft cargo door opened, and the flight crew returned to land at the airport. According to the airplane manufacturer, if the door is not closed and locked, a cockpit light will illuminate indicating that the door is not secure. Following the accident, operation of the door and functionality of the cockpit indicator light were verified. The cargo door indicator light is to be checked by both crewmembers on the Before Takeoff checklist. Due to the flight crew’s lack of professionalism and deviation from standard operating procedures, they most likely did not see that the light was illuminated prior to departure. ## Factual narrative HISTORY OF FLIGHT On March 26, 2008, at 1220 mountain standard time, a Hawker Beechcraft Corporation 1900D, N261GL, operating as Great Lakes Airlines (GLA) flight 5187, made an emergency landing at Page Municipal Airport, Page, Arizona, due to an open cargo door during takeoff. Great Lakes Aviation Limited was operating the airplane under the provisions of 14 Code of Federal Regulations Part 121. The captain, first officer, and 11 passengers were not injured. The airplane sustained minor damage. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight was destined for Four Corners Regional Airport, Farmington, New Mexico. According to the Director of Safety for the airline, just after takeoff, the cargo door opened. The flight crew returned uneventfully to the airport and landed. The flight crew indicated that the cargo door light was not illuminated prior to departure. In the captain's written statement, he reported that 5 to 10 seconds after rotation he noticed the illumination of the cargo door annunciator light. He indicated that before he could reach for the emergency checklist it became clear that the cargo door opened due to the increase in noise. The captain transferred the controls from the first officer and landed the airplane uneventfully. PERSONNEL INFORMATION The captain held an airline transport pilot certificate with single engine and multi-engine land, instrument airplane ratings. The captain also held a first class medical certificate dated November 2007. The medical certificate listed no restrictions or limitations. The company reported the captain as having 3,000 total flying hours, 2,228 hours in the Beech 1900, and 258 hours within the previous 90 days. The captain had successfully completed a company line check ride on June 3, 2007. The first officer held a commercial pilot certificate with single engine and multi-engine land, instrument airplane ratings. The first officer held a first class medical certificate dated October 2006. The medical certificate had a limitation for wearing corrective lenses. The company reported the first officer as having 2,190 total flying hours, 1,085 hours in the Beech 1900, and 200 hours within the previous 90 days. The first officer successfully completed a company line check ride on September 27, 2007. AIRCRAFT INFORMATION The airplane was a Hawker Beechcraft Corporation 1900D, serial number UE-261, twin engine turboprop-powered airplane with a carrying capacity of 2 flight crewmembers, 19 passengers, and baggage. The airplane was manufactured in 1996 and registered to Great Lakes Aviation, Limited, Cheyenne, Wyoming. The airplane is maintained under a Federal Aviation Administration (FAA) approved continuous airworthiness program. A routine continuous airworthiness inspection was performed on March 23, 2008, with an airframe time of 24,065.5 hours. The aft cargo door is located on the left side of the airplane. If the door is not closed and locked, a cockpit light will illuminate indicating that the door is not secure. Following the accident, operation of the door and functionality of the cockpit indicator light were verified. No anomalies were noted. FLIGHT RECORDERS The airplane was equipped with a Cockpit Voice Recorder (CVR) and a Digital Flight Data Recorder (DFDR). Both recorders were removed from the airplane shortly after the incident, and were shipped to the National Transportation Safety Board's Vehicle Recorder Division in Washington, DC, for readout. A CVR Group was formed and the group reviewed the tape recording and developed a CVR transcript. In summary, the recording indicated that as the flight crew went through their checklists, they made comments and jokes about a variety of topics. The checklist items were interspersed with the personal comments. The first officer taxied the airplane as well as briefed the checklist, and the captain commented about the first officer’s control of the airplane during taxi. Approximately 7 seconds after reaching a takeoff safety speed (V2), the sound of increased wind noise was heard through the microphone channel. The flight then returned to land at the departure airport. TESTS AND RESEARCH Safety Board investigators interviewed management personnel regarding the incident. In summary, they indicated that the flight crew had no prior problems or discipline during their employment at the airline. The captain had been employed as a captain for 2 years, and the first officer had been employed by the airline for 2 years. The standard operating procedures specify that the taxi checklist be called out by one crewmember, and verified by the other. GLA management indicated that although the captain will normally taxi the airplane, this item could be delegated to the first officer. Management personnel indicated that the crew acted unprofessionally prior to the cargo door coming open through their lack of professionalism and failure to act in accordance with standard operating procedures. They were not aware of any similar events. As a result of the incident, a bulletin was released to all flight crew personnel to stress the importance of sterile cockpits and professionalism. ADDITIONAL INFORMATION The 14 Code of Federal Regulations Part 121.542 indicates, in part, the following: "(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft. (c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight." According to Section 3.4.1, Exterior Inspection, of the GLA Flight Standards Manual for the Beech 1900D, the cargo compartment, cargo door annunciator circuitry check, and cargo door security and closure should be completed prior to engine start. Additionally, section 3.4.12, Before Takeoff, indicates that all annunciators should be considered and this item is to be verified by both crewmembers. ## Aircraft - Registration: [N261GL](https://openairdocs.org/aircraft/N261GL), registered now, S/N UE-261, built 1996 (OpenAirDocs) - Reported make and model: Raytheon Aircraft Company 1900D - Registry model: [Raytheon 1900D](https://openairdocs.org/model/raytheon-1900d) (registry code 7150005) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: UE261 - Airframe hours: 24078.3 - Engines: Pratt and Whitney PT6A 1100 horsepower turbo prop - Damage: Minor damage - Flight: Part 121 - Operator: Great Lakes Aviation - Registered owner: Great Lakes Aviation - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, March 1, 2008, 12.8 hours before - Departed: PGA, Page, AZ - Destination: FMN, Farmington, NM - Flight plan: IFR - Airport: PGA, Page Municipal, runway 15, 5,950 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: none; airline transport, commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 2, 2007; seat: left; flight hours: 3,000 total, 2,228 in this make and model, 1,408 as pilot in command, 258 in the last 90 days, 73 in the last 30 days, 9 in the last 24 hours - Co-pilot; age 26; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review September 1, 2007; seat: right; flight hours: 2,190 total, 1,085 in this make and model, 940 as pilot in command, 200 in the last 90 days, 65 in the last 30 days, 9 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 16 °F - Altimeter: 30.01 inHg - Observed at: PGA ## 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 20080326835639I](https://openairdocs.org/incident/20080326835639I), Mar 26, 2008: Beech 1900D, Page, AZ, Minor damage. (-23) On March 26,2008, at 1220 MST, a Raytheon aircraft company 1900D, operating as great lakes airlines flight 5187, N261GL, returned to land due to an open… 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.