|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0001 To 0600|
|Locale Reference||atc facility : hnl|
|Altitude||msl bound lower : 9000|
msl bound upper : 9000
|Controlling Facilities||artcc : zhn|
|Operator||common carrier : air taxi|
|Make Model Name||Small Transport, Low Wing, 2 Recip Eng|
|Flight Phase||climbout : intermediate altitude|
|Affiliation||company : air taxi|
|Function||flight crew : single pilot|
|Qualification||pilot : flight engineer|
pilot : commercial
pilot : atp
pilot : instrument
|Experience||flight time last 90 days : 60|
flight time total : 5335
flight time type : 225
|Function||other personnel other|
|Qualification||other other : other|
|Anomaly||aircraft equipment problem : critical|
other anomaly other
|Independent Detector||other flight crewa|
|Resolutory Action||flight crew : declared emergency|
|Consequence||faa : investigated|
During an air ambulance flight from hnl to koa on aug/sat/93 at XA30 local and climbing through 8000 ft MSL, the cabin 'door warn' light came on. After leveling off at 9000 ft MSL, I instructed the medic on board to go to the back of the aircraft and put his seat belt on and then check to see if the door was properly closed. It was apparently not fully closed. As he grabbed the handle to secure it, the door blew open and separated from the aircraft. Upon separation, the door hit the vertical stabilizer approximately 1 ft from the top. The only damage to the tail was approximately 3 square inches of paint missing from the left front portion of the tail. When the door blew off, there was an explosive decompression in the cabin and an accompanying loud rush of air. I instructed the 2 medics aboard to remain calm with their seat belts on and that we would be returning to land in hnl. During the descent and return to hnl, I kept the aircraft below 160 KTS because I was unsure if the aircraft was structurally damaged. However, I did not feel any unusual vibrations or experience any problems with the flight controls. The descent and return for landing in hnl were uneventful. I believe the problem originated with the medic not properly securing the door prior to takeoff. Although I watched him close the door and checked the annunciator panel to ensure the 'door warn' light was out prior to takeoff, I believe the latch in the upper portion of the door was not fully latched to the bottom door. I did not depressurize the cabin prior to asking the medic to check the latch, as I thought changing the pressure forces on the door may have caused it to open anyway. To prevent any future occurrence of this, I will personally close and inspect the door latch and pins prior to engine startup. I will no longer trust the medics to shut the door even though they have been trained how to close and inspect the door to ensure it is properly closed. While I feel the 2 medics on board with me during this flight now understand the importance of ensuring that the latch and pins are secure, I do not believe that the other medics that work for the company do. I will also advise the chief pilot and director of operations that I believe the company should set a procedure that only the pilots should shut the door of the aircraft.
Original NASA ASRS Text
Title: PLT OF AN EMS SMT TWIN ENG ACFT LOST MAIN CABIN DOOR INFLT AND RETURNED TO LAND.
Narrative: DURING AN AIR AMBULANCE FLT FROM HNL TO KOA ON AUG/SAT/93 AT XA30 LCL AND CLBING THROUGH 8000 FT MSL, THE CABIN 'DOOR WARN' LIGHT CAME ON. AFTER LEVELING OFF AT 9000 FT MSL, I INSTRUCTED THE MEDIC ON BOARD TO GO TO THE BACK OF THE ACFT AND PUT HIS SEAT BELT ON AND THEN CHK TO SEE IF THE DOOR WAS PROPERLY CLOSED. IT WAS APPARENTLY NOT FULLY CLOSED. AS HE GRABBED THE HANDLE TO SECURE IT, THE DOOR BLEW OPEN AND SEPARATED FROM THE ACFT. UPON SEPARATION, THE DOOR HIT THE VERT STABILIZER APPROX 1 FT FROM THE TOP. THE ONLY DAMAGE TO THE TAIL WAS APPROX 3 SQUARE INCHES OF PAINT MISSING FROM THE L FRONT PORTION OF THE TAIL. WHEN THE DOOR BLEW OFF, THERE WAS AN EXPLOSIVE DECOMPRESSION IN THE CABIN AND AN ACCOMPANYING LOUD RUSH OF AIR. I INSTRUCTED THE 2 MEDICS ABOARD TO REMAIN CALM WITH THEIR SEAT BELTS ON AND THAT WE WOULD BE RETURNING TO LAND IN HNL. DURING THE DSCNT AND RETURN TO HNL, I KEPT THE ACFT BELOW 160 KTS BECAUSE I WAS UNSURE IF THE ACFT WAS STRUCTURALLY DAMAGED. HOWEVER, I DID NOT FEEL ANY UNUSUAL VIBRATIONS OR EXPERIENCE ANY PROBS WITH THE FLT CTLS. THE DSCNT AND RETURN FOR LNDG IN HNL WERE UNEVENTFUL. I BELIEVE THE PROB ORIGINATED WITH THE MEDIC NOT PROPERLY SECURING THE DOOR PRIOR TO TKOF. ALTHOUGH I WATCHED HIM CLOSE THE DOOR AND CHKED THE ANNUNCIATOR PANEL TO ENSURE THE 'DOOR WARN' LIGHT WAS OUT PRIOR TO TKOF, I BELIEVE THE LATCH IN THE UPPER PORTION OF THE DOOR WAS NOT FULLY LATCHED TO THE BOTTOM DOOR. I DID NOT DEPRESSURIZE THE CABIN PRIOR TO ASKING THE MEDIC TO CHK THE LATCH, AS I THOUGHT CHANGING THE PRESSURE FORCES ON THE DOOR MAY HAVE CAUSED IT TO OPEN ANYWAY. TO PREVENT ANY FUTURE OCCURRENCE OF THIS, I WILL PERSONALLY CLOSE AND INSPECT THE DOOR LATCH AND PINS PRIOR TO ENG STARTUP. I WILL NO LONGER TRUST THE MEDICS TO SHUT THE DOOR EVEN THOUGH THEY HAVE BEEN TRAINED HOW TO CLOSE AND INSPECT THE DOOR TO ENSURE IT IS PROPERLY CLOSED. WHILE I FEEL THE 2 MEDICS ON BOARD WITH ME DURING THIS FLT NOW UNDERSTAND THE IMPORTANCE OF ENSURING THAT THE LATCH AND PINS ARE SECURE, I DO NOT BELIEVE THAT THE OTHER MEDICS THAT WORK FOR THE COMPANY DO. I WILL ALSO ADVISE THE CHIEF PLT AND DIRECTOR OF OPS THAT I BELIEVE THE COMPANY SHOULD SET A PROC THAT ONLY THE PLTS SHOULD SHUT THE DOOR OF THE ACFT.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.