CESSNA 560XL near White Plains, NY — 2010-05-28

Probable cause

The flight crew's failure to ensure that the cabin door was secured/locked prior to takeoff.

NTSB narrative

After concluding the preflight safety briefing for the passengers, the first officer closed the cabin door. The first officer remembered rotating the door locking handle but could not recall the direction he rotated it. He also could not recall looking at the cabin door lock indicator lights or the cockpit indicator, as was required by the operator's preflight checklist. Just after takeoff, the captain recalled that he heard the cabin door "leaking" and the first officer observed that the DOOR SEAL/CABIN DOOR annunciator lights were illuminated. When asked, the first officer did not recall the MASTER CAUTION annunciator illuminating. Had the MASTER CAUTION annunciator illuminated, it would have been one indication that the door was properly secured prior to the takeoff. While on the downwind leg of the traffic pattern during the return for landing, the main cabin door opened. The crew subsequently declared an emergency, and landed uneventfully with the main cabin door open. The airplane incurred minor damage during the landing and the passengers and crew were not injured. Postincident examination of the door and its locking and indicating mechanisms revealed no evidence of any mechanical malfunctions or failures. Because of the close proximity of the amber-colored CABIN DOOR annunciator light and the white-colored GROUND IDLE annunciator light, it is possible that the flight crew inadvertently overlooked the illuminated CABIN DOOR annunciator light prior to takeoff.

Analysis

Primary failure mode

Human factors

First missed decision gate

First officer should have verified door locking indicators before takeoff.

NTSB coding

• Miscellaneous/other · Approach-VFR pattern downwind
• Preflight Inspection

Evidence available

• CVR
• Photos
• 9 docket documents

Docket documents9

• Cockpit Voice Recorder 12 - Factual Report of Group Chairmancvr
• Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
• FAA Inspector's Statementinterview
• Flight Crew Statementsinterview
• Statement of Party Representatives to NTSB Investigationinterview
• Annunciator Diagramother
• Maintenance Manual Excerptsother
• Operator's Checklist Excerptother
• Photo - Damage to Cabin Door (Photo Courtesy of FAA)photos

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