37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 102208 |
Time | |
Date | 198801 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : fat |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 700 |
Environment | |
Flight Conditions | Marginal |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : fat |
Operator | common carrier : air carrier |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : takeoff ground : parked ground : preflight |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3200 flight time type : 1200 |
ASRS Report | 102208 |
Person 2 | |
Affiliation | company : air carrier |
Function | observation : observer |
Qualification | other other : other |
ASRS Report | 102207 |
Events | |
Anomaly | aircraft equipment problem : less severe |
Independent Detector | other flight crewa other other : unspecified |
Resolutory Action | none taken : unable other |
Consequence | Other |
Supplementary | |
Primary Problem | Airport |
Air Traffic Incident | other |
Narrative:
The right forward emergency exit popped open just after takeoff. The safety catch held, the exit remained ajar and did not break away. A passenger was seated next to the exit. We heard the 'poof' when the window opened and looked back and saw that passenger' hair blowing in the wind. We told the tower we wanted to return. They immediately cleared us to land and asked if we wanted any equipment standing by. We declined the equipment. We flew the pattern at 700' AGL to remain clear of clouds and landed west/O further incident. The aircraft had all inspections signed off when we originally received it. I noticed the safety catch hanging loose on the exit during the preflight and had a mechanic fix it. The exit is not murphy-proof. It looked secure to all concerned when it wasn't. The aircraft had been used for crew emergency exit training the previous day. A breakdown in communication caused the door not to get get resecured and inspected. Supplemental information from acn 102207: the on-sight mechanic did not fully ascertain proper closure even though all indicators were to the contrary. The air carrier is taking 3 courses of action: counseled individuals involved with the problem, amend current maintenance (a-chk) and flight crews preflight checks for visibility positive engagement of the shoot-bolts of the door(south) into the adjacent fuselage structure, and policy change for the training of flight crews to make a written statement re: which door/panel opened/removed on the airplane flight log book-maintenance discrepancy and to not close or reinstall and doors/panels after they have completed their training session.
Original NASA ASRS Text
Title: EMERGENCY EXIT CAME OPEN AFTER TKOF ON COMMUTER SMT.
Narrative: THE RIGHT FORWARD EMER EXIT POPPED OPEN JUST AFTER TKOF. THE SAFETY CATCH HELD, THE EXIT REMAINED AJAR AND DID NOT BREAK AWAY. A PAX WAS SEATED NEXT TO THE EXIT. WE HEARD THE 'POOF' WHEN THE WINDOW OPENED AND LOOKED BACK AND SAW THAT PAX' HAIR BLOWING IN THE WIND. WE TOLD THE TWR WE WANTED TO RETURN. THEY IMMEDIATELY CLRED US TO LAND AND ASKED IF WE WANTED ANY EQUIP STANDING BY. WE DECLINED THE EQUIP. WE FLEW THE PATTERN AT 700' AGL TO REMAIN CLR OF CLOUDS AND LANDED W/O FURTHER INCIDENT. THE ACFT HAD ALL INSPECTIONS SIGNED OFF WHEN WE ORIGINALLY RECEIVED IT. I NOTICED THE SAFETY CATCH HANGING LOOSE ON THE EXIT DURING THE PREFLT AND HAD A MECH FIX IT. THE EXIT IS NOT MURPHY-PROOF. IT LOOKED SECURE TO ALL CONCERNED WHEN IT WASN'T. THE ACFT HAD BEEN USED FOR CREW EMER EXIT TRNING THE PREVIOUS DAY. A BREAKDOWN IN COM CAUSED THE DOOR NOT TO GET GET RESECURED AND INSPECTED. SUPPLEMENTAL INFO FROM ACN 102207: THE ON-SIGHT MECH DID NOT FULLY ASCERTAIN PROPER CLOSURE EVEN THOUGH ALL INDICATORS WERE TO THE CONTRARY. THE ACR IS TAKING 3 COURSES OF ACTION: COUNSELED INDIVIDUALS INVOLVED WITH THE PROB, AMEND CURRENT MAINT (A-CHK) AND FLT CREWS PREFLT CHKS FOR VIS POSITIVE ENGAGEMENT OF THE SHOOT-BOLTS OF THE DOOR(S) INTO THE ADJACENT FUSELAGE STRUCTURE, AND POLICY CHANGE FOR THE TRNING OF FLT CREWS TO MAKE A WRITTEN STATEMENT RE: WHICH DOOR/PANEL OPENED/REMOVED ON THE AIRPLANE FLT LOG BOOK-MAINT DISCREPANCY AND TO NOT CLOSE OR REINSTALL AND DOORS/PANELS AFTER THEY HAVE COMPLETED THEIR TRNING SESSION.
Data retrieved from NASA's ASRS site as of August 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.