Serious incident British Aerospace 3201 Jetstream 31 N844AE,
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ASN Wikibase Occurrence # 365736
 
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Date:Thursday 31 January 1991
Time:20:37 LT
Type:Silhouette image of generic JS31 model; specific model in this crash may look slightly different    
British Aerospace 3201 Jetstream 31
Owner/operator:Nashville Eagle
Registration: N844AE
MSN: 844
Engine model:GARRETT TPR331-12UAR
Fatalities:Fatalities: 0 / Occupants: 5
Aircraft damage: Minor
Category:Serious incident
Location:Charlotte, NC -   United States of America
Phase: Standing
Nature:Unknown
Departure airport:Charlotte, NC (KCLT)
Destination airport:Nashville, TN (KBNA)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
AFTER THE NO. 2 ENGINE STARTED, THE FLIGHT CREW NOTICED A CABIN DOOR OPEN LIGHT. THE CAPTAIN SHUT DOWN THE NO. 1 ENGINE, AND SIGNALED TO THE GROUND CREW TO CHECK THE DOOR. THE CAPTAIN RECYCLED THE DOOR WARNING CIRCUIT BREAKER SEVERAL TIMES, AND THE LIGHT EXTINGUISHED. ON CLIMBOUT, PASSING 7,000 FEET, THE CABIN DOOR SUDDENLY SEPARATED FROM THE AIRPLANE. THE FLIGHT RETURNED TO THE DEPARTURE AIRPORT AND LANDED WITHOUT FURTHER PROBLEMS. THE INVESTIGATION REVEALED THAT THE GROUND CREW DID NOT UNDERSTAND THE CAPTAIN'S INTENTIONS, AND DID NOT CHECK THE DOOR FOR SECURITY. THE CAPTAIN DID NOT FOLLOW CHECKLIST PROCEDURES FOR DEALING WITH A DOOR LIGHT ON THE GROUND. THE RAMP AGENT, THE LAST PERSON TO CLOSE THE DOOR, HAD NOT OPERATED JETSTREAM DOORS PRIOR TO THE DAY OF THE INCIDENT. EXAMINATION OF THE AIRCRAFT AND THE RECOVERED DOOR REVEALED NO EVIDENCE OF MALFUNCTION OR FAILURE.

Probable Cause: THE FAILURE OF THE CAPTAIN TO FOLLOW CHECKLIST PROCEDURES, RESULTING IN A FLIGHT WITH THE CABIN DOOR UNSECURED, AND THE SUBSEQUENT LOSS OF THE CABIN DOOR.

Accident investigation:
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Investigating agency: NTSB
Report number: ATL91IA044
Status: Investigation completed
Duration: 2 years and 3 months
Download report: Final report

Sources:

NTSB ATL91IA044

Revision history:

Date/timeContributorUpdates
20-Mar-2024 13:19 ASN Update Bot Added

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