SEA97LA085

NTSB accident investigation · Beech 1900D · Portland, OR · April 6, 1997

Accident · No injuriesLimited investigationFinal report
Date
April 6, 1997, 13:48 local (20:48 UTC)
Place
Portland, OR
Injuries
14 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N75ZVBeech 1900D
Weather
Visual (VMC) · Day
Status
Completed · report April 10, 1998
Report
Approved by Office Director
FAA report
19970406005949A
Case key
42584

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 flightcrew's inadequate preflight, and the ramp agent's inadequate dispatch of the aircraft. The unsecured cargo door was a factor.

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.

Miscellaneous/otherTakeoff - initial climb
Door,cargo/baggage - not securedFactor
Aircraft preflight - inadequateFlightcrewCause
Dispatch - inadequateGround personnelCause

Analysis

The ramp agent handling the flight, who is required by company procedures to check doors secured during a pre-departure check, stated, '...upon my releasing them to taxi I did not notice anything different, all doors were closed.' The captain reported that as the gear was brought up on takeoff, the flightcrew heard a 'loud wind noise.' He stated that they had no indications of anything wrong on the annunciator panel (which contains a red CARGO DOOR warning light to indicate that the cargo door is open or not secure.) He reported that they then looked in the back of the aircraft, and the passengers told them that the cargo door had come open. The crew then returned to land. An inventory of the cargo compartment contents after landing revealed that no baggage had been lost. During postaccident examination of the aircraft, the aft cargo door locking handle was observed in the unlocked position as the door was swung down, and visual inspection of the aft cargo door locks, switches, and annunciator cargo door warning systems found no discrepancies with the aft cargo door or its indicating/warning system.

Factual narrative

On April 6, 1997, approximately 1348 Pacific daylight time, a Beech 1900D, N75ZV, owned by Mesa Airlines and operating as Air Shuttle flight 7793 (a United Express flight), was substantially damaged when the aft cargo door opened on takeoff from Portland International Airport, Portland, Oregon. The 14 CFR 121 scheduled domestic passenger/cargo flight, with a planned destination of Yakima, Washington, returned to Portland and landed without further incident. There were no injuries to the airline transport pilot-in-command, first officer, or 12 passengers on board. Visual meteorological conditions existed at the time, and the flight was on an instrument flight rules (IFR) flight plan.

The Mesa ramp agent who handled the departing flight from Portland reported that as the last passenger was boarding the aircraft, additional baggage was brought to the aircraft which necessitated reopening the aft cargo door, which had already been closed for departure. The ramp agent stated that after loading the bags, she took the baggage slip to the captain while the first officer closed the aft cargo door. She stated that "as the aft of the plane passed by me upon my releasing them to taxi I did not notice anything different, all doors were closed." Another Mesa ramp agent who saw the aircraft taxi out reported that as the aircraft passed by her, she "seemed to notice that the aft lock looked unlocked but I was bringing in a plane at the same time and was concerned with that plane."

The captain reported that as the gear was brought up on takeoff, the flight crew heard a "loud wind noise." He stated that they had no indications of anything wrong on the annunciator panel (which contains a red CARGO DOOR warning light to indicate that the cargo door is open or not secure.) He reported that they then looked in the back of the aircraft, and the passengers told them that the cargo door had come open. The crew then returned to Portland and landed. An inventory of the cargo compartment contents after landing revealed that no baggage had been lost.

The FAA inspector assigned to the accident reported that upon post-accident examination of the aircraft, the aft cargo door locking handle was observed in the unlocked position as the door was swung down, and that visual inspection of the aft cargo door locks, switches, and annunciator cargo door warning systems found no discrepancies with the aft cargo door or its indicating/warning system.

The Mesa station operations manual assigns responsibility to the ramp agent handling a flight to check that cargo doors are locked during a pre-departure walkaround. The aircraft's flight crew checklist also instructs the flight crew to check that cargo and cabin doors are secured, and to check the warning annunciator lights, before engine start.

Aircraft

Registration
N75ZV
Reported as
Beech 1900D
Category
Airplane
Serial number
UE-75
Engine
P&W PT6A-67D, 1,250 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 121
Registered owner
Mesa Airlines Inc.
Airworthiness certificate
Standard, Normal
Departed
PDX
Destination
YKM · Yakima, WA
Flight plan
IFR
Airport
KPDX · Portland International, runway 10L, 8,000 × 150 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
8,500 total · 3,500 in this make and model · 8,500 as pilot in command · 240 in the last 90 days · 80 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F

FAA reports on this event · 1

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