Pilot Debrief

EMBRAER S A EMB-545 near Houston, TX — 2022-10-03

Final reportCEN23LA003
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Date
2022-10-03
Location
Houston, TX, USA
Aircraft
EMBRAER S A EMB-545
Registration
N179SP
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

The crew failed to ensure the main entry door was locked before departure. Contributing to the accident was a corroded/jammed door sensor that provided an erroneous locked indication to the crew alerting system.

Contributing factors

Contributing to the accident was a corroded/jammed door sensor that provided an erroneous locked indication to the crew alerting system.

NTSB narrative

The two pilots departed on a business flight with two passengers and observed that the airplane did not pressurize during the initial climb out. As the climb continued, the crew observed a door open warning on the crew alerting system (CAS). The pilot in command (PIC), seated in the right seat, got out of his seat to check the door and attempted to push the handle down toward the locked position, but stated that “it kept coming up.” About 14 seconds after the PIC got out of his seat, the main cabin door opened inflight, which resulted in substantial damage to the door and fuselage. The PIC returned to his seat and commented several times that the second in command (SIC) had not secured the door. The flight returned to land without further incident. Postaccident examination revealed no anomalies that would have prevented the door from a normal sequence of closing, latching, and locking. A corroded/jammed locked sensor assembly was observed that erroneously indicated a locked door to the CAS when the door was actually only latched but not locked. However, the two visual locked indications on the door functioned properly, which was consistent with the crew not fully closing the door or observing the unsafe (red) visual locked indicators. During climb out, the aerodynamic forces on the door and/or airplane vibration likely caused the target for closed door sensor to move away from the sensor, which triggered the CAS door open warning. The aerodynamic forces on the door, airplane vibration, and/or the PIC’s handle movement likely allowed the door to open inflight.

Analysis

Primary failure mode
Human factors
First missed decision gate
PIC should have verified door closure before takeoff.

NTSB coding

Evidence available

  • CVR
  • FDR / data
  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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