Narrative:

I was the PIC of post maintenance/reposition flight operating a canadair 600 series jet under far part 91 regulations. After an all day wait for minor; unscheduled maintenance to be performed and completed we boarded the plane. The sic closed the passenger door for the flight. I was in the cabin doorway supervising and waiting for him to complete the closing. I watched him close the door normally and advised him of such. We entered the cockpit and took our seats. It is customary for me to glance at the door annunciator panel upon taking my seat and I don't recall seeing the amber 'passenger door unlocked/not ready' lights illuminated. We accomplished the before start flow and checklist. We had 2 normal starts and completed the after start flow and checklist noting nothing abnormal. The taxi checks were accomplished while taxiing to the departure runway. We were instructed to hold short of the runway and to contact the tower for clearance. Upon receiving our takeoff clearance we performed the takeoff flow and checklist and departed normally. A climbing right turn toward our destination was initiated. Upon leveling the wings we heard a loud 'bang' with an accompanying rush of air. I turned my head back toward the cabin and noticed the doorway was void of the cabin door. At this point I simultaneously assumed the PF duties; turned the aircraft toward the departure airport and tried to verbally declare an emergency. Attempts to contact the tower via VHF were unsuccessful from either seat. A transponder code of 7700 was selected. We could hear the tower clearing the pattern for our return. I configured the aircraft for landing noticing normal control inputs and responses. We landed and rolled out using normal reverse thrust and braking and cleared the runway. We stopped the aircraft on the adjoining taxiway; went through the shutdown checklist; and secured the aircraft. I feel that the outcome of our flight was caused by a mechanical irregularity. I have; however; also idented several factors related to human performance; which; I believe; might have contributed to this incident. I have broken them down into 4 groups: operation considerations; 2) the maintenance event; 3) the aircraft manuals/training; and 4) the aircraft malfunction/mechanical irregularity. Operation considerations: the day of the incident was my 24TH day of flight duty in a 25 day period. Our company was under a big 'push' to get our sales customers to our domestic and international properties. Trying to accommodate and coordinate all of the flying requested of the flight department within the confines of our soon-to-be-due 300/600 hour inspection as well as duty time limitations and regulations had been a constant pressure. I was physically; mentally and emotionally exhausted. Our monday through wednesday trip for the following week had been canceled; so I made the decision to get some maintenance items addressed during that 3 day break. We had returned to our home base saturday night. Our duty day that day was too long to continue to our maintenance provider's base to drop the plane off that night. My usual co-captain had the opportunity to commute to his home to be with family; so I decided to use our alternate sic to fly with me on the local repositioning flight. He had flown with me on other maintenance flts and we had completed his far part 91 sic check-out; as required by far part 61.55. We had originally planned to leave the aircraft at the shop a few days when he and I would pick it up. As such; we rented a car to drive back to home base to perform administrative duties. We had lunch and were ready to leave town; but decided to make 1 last swing by the maintenance provider's shop to check up on the aircraft before we left. When we arrived we learned that the maintenance crew was finishing the required maintenance items and was getting ready for a ground check run. We were advised that they would finish within the hour. During this time; the company informed me of a new trip. In order to eliminate a new logistical challenge; the sic and I discussed and agreed to wait for the plane and return it to home base once it was ready that evening. Once the maintenance items were completed; I accomplished a cockpit check; pre-start flow and checklist; started the engines and accompanied the maintenance crew to the run-up area. During the checking of their work the avionics crew adjusted the cockpit interphone volumes with the engines running. After approximately 10 mins; I shut down the engines and secured the plane. Maintenance event: throughout the day and particularly during the hour and half before departure we were in and out of the cockpit powering up and shutting down while we were involved in several mentally demanding exchanges with the maintenance team. During the course of events that afternoon I performed different checklists several times in what was an intense environment of change. The aircraft had many maintenance people in and out of the cockpit; cabin and 'hell hole' continually. Once the maintenance actions were completed I accomplished several checklist items in anticipation of our departure. Close attention was paid to the circuit breaker panel and in particular the air driven generator (air driven generator) circuit breakers; as it is common for maintenance personnel to pull these breakers during maintenance. (This action prevents an inadvertent deployment of the air driven generator on the ground during power xfers.) aircraft manuals/training: the training facility which provided my initial training used only a slide show presentation to teach and demonstrate proper cabin door operations. No 'hands on' training was available via a door training device or cabin mock up. Since our incident; we have learned that ours was not the first such happening with this series of aircraft. We're told that a lawsuit was filed when a series 600 aircraft door opened in-flight and departed the aircraft in a similar fashion. Fault was found with the equipment. During my initial training; this incident was never mentioned or discussed. Aircraft malfunction/mechanical irregularity: after our event the aircraft was inspected. During the inspection it was found that; with all door indicator switches actuated manually; the 'passenger door unlocked' annunciator light would not illuminate; even with the external handle in a non-stowed position. Our aircraft does have a master takeoff confign warning system; but the aircraft doors are not integrated into it; as they are on other aircraft. Other manufacturers have realized the importance of this feature. I believe that a takeoff confign warning system wired to the aircraft doors would be another aid to alert the crew of this kind of mechanical irregularity; and; perhaps; prevent further incidents of this kind.

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Original NASA ASRS Text

Title: A CL60 CABIN DOOR OPENED SHORTLY AFTER TKOF. AN EMER WAS DECLARED. THE 'DOOR UNLOCKED' WARNING FAILED TO ALERT THE CREW OF DOOR STATUS ON PREFLT.

Narrative: I WAS THE PIC OF POST MAINT/REPOSITION FLT OPERATING A CANADAIR 600 SERIES JET UNDER FAR PART 91 REGS. AFTER AN ALL DAY WAIT FOR MINOR; UNSCHEDULED MAINT TO BE PERFORMED AND COMPLETED WE BOARDED THE PLANE. THE SIC CLOSED THE PAX DOOR FOR THE FLT. I WAS IN THE CABIN DOORWAY SUPERVISING AND WAITING FOR HIM TO COMPLETE THE CLOSING. I WATCHED HIM CLOSE THE DOOR NORMALLY AND ADVISED HIM OF SUCH. WE ENTERED THE COCKPIT AND TOOK OUR SEATS. IT IS CUSTOMARY FOR ME TO GLANCE AT THE DOOR ANNUNCIATOR PANEL UPON TAKING MY SEAT AND I DON'T RECALL SEEING THE AMBER 'PAX DOOR UNLOCKED/NOT READY' LIGHTS ILLUMINATED. WE ACCOMPLISHED THE BEFORE START FLOW AND CHKLIST. WE HAD 2 NORMAL STARTS AND COMPLETED THE AFTER START FLOW AND CHKLIST NOTING NOTHING ABNORMAL. THE TAXI CHKS WERE ACCOMPLISHED WHILE TAXIING TO THE DEP RWY. WE WERE INSTRUCTED TO HOLD SHORT OF THE RWY AND TO CONTACT THE TWR FOR CLRNC. UPON RECEIVING OUR TKOF CLRNC WE PERFORMED THE TKOF FLOW AND CHKLIST AND DEPARTED NORMALLY. A CLBING R TURN TOWARD OUR DEST WAS INITIATED. UPON LEVELING THE WINGS WE HEARD A LOUD 'BANG' WITH AN ACCOMPANYING RUSH OF AIR. I TURNED MY HEAD BACK TOWARD THE CABIN AND NOTICED THE DOORWAY WAS VOID OF THE CABIN DOOR. AT THIS POINT I SIMULTANEOUSLY ASSUMED THE PF DUTIES; TURNED THE ACFT TOWARD THE DEP ARPT AND TRIED TO VERBALLY DECLARE AN EMER. ATTEMPTS TO CONTACT THE TWR VIA VHF WERE UNSUCCESSFUL FROM EITHER SEAT. A XPONDER CODE OF 7700 WAS SELECTED. WE COULD HEAR THE TWR CLRING THE PATTERN FOR OUR RETURN. I CONFIGURED THE ACFT FOR LNDG NOTICING NORMAL CTL INPUTS AND RESPONSES. WE LANDED AND ROLLED OUT USING NORMAL REVERSE THRUST AND BRAKING AND CLRED THE RWY. WE STOPPED THE ACFT ON THE ADJOINING TXWY; WENT THROUGH THE SHUTDOWN CHKLIST; AND SECURED THE ACFT. I FEEL THAT THE OUTCOME OF OUR FLT WAS CAUSED BY A MECHANICAL IRREGULARITY. I HAVE; HOWEVER; ALSO IDENTED SEVERAL FACTORS RELATED TO HUMAN PERFORMANCE; WHICH; I BELIEVE; MIGHT HAVE CONTRIBUTED TO THIS INCIDENT. I HAVE BROKEN THEM DOWN INTO 4 GROUPS: OP CONSIDERATIONS; 2) THE MAINT EVENT; 3) THE ACFT MANUALS/TRAINING; AND 4) THE ACFT MALFUNCTION/MECHANICAL IRREGULARITY. OP CONSIDERATIONS: THE DAY OF THE INCIDENT WAS MY 24TH DAY OF FLT DUTY IN A 25 DAY PERIOD. OUR COMPANY WAS UNDER A BIG 'PUSH' TO GET OUR SALES CUSTOMERS TO OUR DOMESTIC AND INTL PROPERTIES. TRYING TO ACCOMMODATE AND COORDINATE ALL OF THE FLYING REQUESTED OF THE FLT DEPT WITHIN THE CONFINES OF OUR SOON-TO-BE-DUE 300/600 HR INSPECTION AS WELL AS DUTY TIME LIMITATIONS AND REGS HAD BEEN A CONSTANT PRESSURE. I WAS PHYSICALLY; MENTALLY AND EMOTIONALLY EXHAUSTED. OUR MONDAY THROUGH WEDNESDAY TRIP FOR THE FOLLOWING WEEK HAD BEEN CANCELED; SO I MADE THE DECISION TO GET SOME MAINT ITEMS ADDRESSED DURING THAT 3 DAY BREAK. WE HAD RETURNED TO OUR HOME BASE SATURDAY NIGHT. OUR DUTY DAY THAT DAY WAS TOO LONG TO CONTINUE TO OUR MAINT PROVIDER'S BASE TO DROP THE PLANE OFF THAT NIGHT. MY USUAL CO-CAPT HAD THE OPPORTUNITY TO COMMUTE TO HIS HOME TO BE WITH FAMILY; SO I DECIDED TO USE OUR ALTERNATE SIC TO FLY WITH ME ON THE LCL REPOSITIONING FLT. HE HAD FLOWN WITH ME ON OTHER MAINT FLTS AND WE HAD COMPLETED HIS FAR PART 91 SIC CHK-OUT; AS REQUIRED BY FAR PART 61.55. WE HAD ORIGINALLY PLANNED TO LEAVE THE ACFT AT THE SHOP A FEW DAYS WHEN HE AND I WOULD PICK IT UP. AS SUCH; WE RENTED A CAR TO DRIVE BACK TO HOME BASE TO PERFORM ADMINISTRATIVE DUTIES. WE HAD LUNCH AND WERE READY TO LEAVE TOWN; BUT DECIDED TO MAKE 1 LAST SWING BY THE MAINT PROVIDER'S SHOP TO CHK UP ON THE ACFT BEFORE WE LEFT. WHEN WE ARRIVED WE LEARNED THAT THE MAINT CREW WAS FINISHING THE REQUIRED MAINT ITEMS AND WAS GETTING READY FOR A GND CHK RUN. WE WERE ADVISED THAT THEY WOULD FINISH WITHIN THE HR. DURING THIS TIME; THE COMPANY INFORMED ME OF A NEW TRIP. IN ORDER TO ELIMINATE A NEW LOGISTICAL CHALLENGE; THE SIC AND I DISCUSSED AND AGREED TO WAIT FOR THE PLANE AND RETURN IT TO HOME BASE ONCE IT WAS READY THAT EVENING. ONCE THE MAINT ITEMS WERE COMPLETED; I ACCOMPLISHED A COCKPIT CHK; PRE-START FLOW AND CHKLIST; STARTED THE ENGS AND ACCOMPANIED THE MAINT CREW TO THE RUN-UP AREA. DURING THE CHKING OF THEIR WORK THE AVIONICS CREW ADJUSTED THE COCKPIT INTERPHONE VOLUMES WITH THE ENGS RUNNING. AFTER APPROX 10 MINS; I SHUT DOWN THE ENGS AND SECURED THE PLANE. MAINT EVENT: THROUGHOUT THE DAY AND PARTICULARLY DURING THE HR AND HALF BEFORE DEP WE WERE IN AND OUT OF THE COCKPIT POWERING UP AND SHUTTING DOWN WHILE WE WERE INVOLVED IN SEVERAL MENTALLY DEMANDING EXCHANGES WITH THE MAINT TEAM. DURING THE COURSE OF EVENTS THAT AFTERNOON I PERFORMED DIFFERENT CHKLISTS SEVERAL TIMES IN WHAT WAS AN INTENSE ENVIRONMENT OF CHANGE. THE ACFT HAD MANY MAINT PEOPLE IN AND OUT OF THE COCKPIT; CABIN AND 'HELL HOLE' CONTINUALLY. ONCE THE MAINT ACTIONS WERE COMPLETED I ACCOMPLISHED SEVERAL CHKLIST ITEMS IN ANTICIPATION OF OUR DEP. CLOSE ATTN WAS PAID TO THE CIRCUIT BREAKER PANEL AND IN PARTICULAR THE AIR DRIVEN GENERATOR (ADG) CIRCUIT BREAKERS; AS IT IS COMMON FOR MAINT PERSONNEL TO PULL THESE BREAKERS DURING MAINT. (THIS ACTION PREVENTS AN INADVERTENT DEPLOYMENT OF THE ADG ON THE GND DURING PWR XFERS.) ACFT MANUALS/TRAINING: THE TRAINING FACILITY WHICH PROVIDED MY INITIAL TRAINING USED ONLY A SLIDE SHOW PRESENTATION TO TEACH AND DEMONSTRATE PROPER CABIN DOOR OPS. NO 'HANDS ON' TRAINING WAS AVAILABLE VIA A DOOR TRAINING DEVICE OR CABIN MOCK UP. SINCE OUR INCIDENT; WE HAVE LEARNED THAT OURS WAS NOT THE FIRST SUCH HAPPENING WITH THIS SERIES OF ACFT. WE'RE TOLD THAT A LAWSUIT WAS FILED WHEN A SERIES 600 ACFT DOOR OPENED INFLT AND DEPARTED THE ACFT IN A SIMILAR FASHION. FAULT WAS FOUND WITH THE EQUIP. DURING MY INITIAL TRAINING; THIS INCIDENT WAS NEVER MENTIONED OR DISCUSSED. ACFT MALFUNCTION/MECHANICAL IRREGULARITY: AFTER OUR EVENT THE ACFT WAS INSPECTED. DURING THE INSPECTION IT WAS FOUND THAT; WITH ALL DOOR INDICATOR SWITCHES ACTUATED MANUALLY; THE 'PAX DOOR UNLOCKED' ANNUNCIATOR LIGHT WOULD NOT ILLUMINATE; EVEN WITH THE EXTERNAL HANDLE IN A NON-STOWED POS. OUR ACFT DOES HAVE A MASTER TKOF CONFIGN WARNING SYS; BUT THE ACFT DOORS ARE NOT INTEGRATED INTO IT; AS THEY ARE ON OTHER ACFT. OTHER MANUFACTURERS HAVE REALIZED THE IMPORTANCE OF THIS FEATURE. I BELIEVE THAT A TKOF CONFIGN WARNING SYS WIRED TO THE ACFT DOORS WOULD BE ANOTHER AID TO ALERT THE CREW OF THIS KIND OF MECHANICAL IRREGULARITY; AND; PERHAPS; PREVENT FURTHER INCIDENTS OF THIS KIND.

Data retrieved from NASA's ASRS site as of May 2009 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.