Narrative:

I have been on many flts where ramp personnel have forgotten to close a cargo door. Ordinarily, most pilots working for my company consider these incidences to be more of a hassle than a serious safety threat because we often catch this mistake with the 'cargo door unlocked' annunciator (in my experience approximately once every 30 hours of flying time). It appears from talking with ramp personnel that the cargo door was left closed but not locked -- this is common practice. The reason for this is that the company had an incident in which a cargo door had been damaged by another aircraft's wake, and had subsequently prohibited ramp personnel from leaving the door open while not loading cargo. The problem with this is that it is very easy for someone to miss a door that is closed but unlocked, prior to releasing the aircraft to taxi. The company has corrected this problem by mandating that the door has 2 position: open, or closed and locked. Another contributing factor appears to be that no one on the ramp seemed to be sure who's responsibility it was to close the door. Although it is the company's policy that the person who marshalls the aircraft is responsible for verifying that the cargo door is closed, it didn't seem to me that the ramp personnel present understood this. About 10 mins prior to the flight, I was in the right seat to get a clearance and do the manifest (weight and balance). The captain was busy loading the passenger. I believe the captain shut the cabin door while the ramp personnel were still loading excess carry-on baggage in the rear cargo hold, and thus relied on the ramp personnel to check that the cargo door was properly secured. This is normal practice, and I would consider it to have been unusual if the captain had delayed the flight by personally checking the security of the cargo door. The captain performed all checklists, as usual. The checklists include testing the annunciator system, and verifying that the cabin door and cargo door annunciators are extinguished. The captain later claimed that all annunciators checked properly (with the exception of the cabin door annunciator which was inoperative, and was a deferred maintenance discrepancy per the aircraft's MEL) and that the cargo door annunciator was extinguished. I can't verify that the annunciators tested properly, because I was finishing the manifest while the captain performed this check, however, all warning annunciators were extinguished when we taxied. Everything was normal until about 300 ft AGL on departure. At this point the airplane began to shudder, and the cabin cockpit was filled with a loud, low-frequency, throbbing sound. My first reaction was that the aircraft had lost part of a propeller or that something was wrong with one of the engines. Nothing on the engine gages indicated any engine trouble. The captain retarded the propellers, but this produced no change in the vibration pattern. Next, the captain reached to test the annunciators -- which were all extinguished. After hitting the test button, the cargo door annunciator remained illuminated. We returned for an immediate and uneventful landing, and the aircraft's handling characteristics (as far as I could tell as PNF) did not seem to be adversely affected. The aircraft received minor damage to the cargo door hinge, and a dent along the vertical stabilizer, strake, but was otherwise ok. Later, in taxiing the aircraft to the maintenance hangar, the cargo door annunciator again failed to illuminate. The captain was able to get it to illuminate by touching it, lightly, with his hand. The annunciators are deactivated by pressing and releasing the annunciator face. Once you do this, the face pops out, the annunciator is deactivated, and if you pull further, the annunciator bulb assembly comes all the way out, so that you can change the light bulb. Apparently, the cargo door annunciator was only making intermittent electrical contact. In summary, there are several factors I believe lead to this incident: the unsafe practice of leaving the cargo door closed, but unlocked (since corrected). Human performance: there should be 1 person running the show on theramp for a particular aircraft, and no doubt about who that person is, that person should check that the cargo door is closed prior to taxi, and should not delegate this responsibility. The pilot who is loading the passenger should visually check to see that the cargo door is in the horizontal (ie, locked) position prior to taxi, and better yet, check the door him or herself, since our ramp personnel cannot be trusted. Checking the annunciator integrity is critical, although in rare cases, it is possible that this may not ensure that the door is closed. Annunciator design: it would be better to design the annunciators such that they continue to make electrical contact until they are pulled all the way out, instead of only making electrical contact when they are all the way in -- this would reduce the potential for false positives caused by annunciators that are not properly seated in their socket.

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Original NASA ASRS Text

Title: BE1900 CARGO DOOR COMES OPEN INFLT DURING INITIAL CLB FROM PHX. DOOR WARNING ANNUNCIATOR HAD FAILED TO INDICATE ANY OPEN OR UNLOCKED DOOR WHILE ON RAMP OR AIRBORNE. RETURN LAND AFTER EMER DECLARED.

Narrative: I HAVE BEEN ON MANY FLTS WHERE RAMP PERSONNEL HAVE FORGOTTEN TO CLOSE A CARGO DOOR. ORDINARILY, MOST PLTS WORKING FOR MY COMPANY CONSIDER THESE INCIDENCES TO BE MORE OF A HASSLE THAN A SERIOUS SAFETY THREAT BECAUSE WE OFTEN CATCH THIS MISTAKE WITH THE 'CARGO DOOR UNLOCKED' ANNUNCIATOR (IN MY EXPERIENCE APPROX ONCE EVERY 30 HRS OF FLYING TIME). IT APPEARS FROM TALKING WITH RAMP PERSONNEL THAT THE CARGO DOOR WAS LEFT CLOSED BUT NOT LOCKED -- THIS IS COMMON PRACTICE. THE REASON FOR THIS IS THAT THE COMPANY HAD AN INCIDENT IN WHICH A CARGO DOOR HAD BEEN DAMAGED BY ANOTHER ACFT'S WAKE, AND HAD SUBSEQUENTLY PROHIBITED RAMP PERSONNEL FROM LEAVING THE DOOR OPEN WHILE NOT LOADING CARGO. THE PROB WITH THIS IS THAT IT IS VERY EASY FOR SOMEONE TO MISS A DOOR THAT IS CLOSED BUT UNLOCKED, PRIOR TO RELEASING THE ACFT TO TAXI. THE COMPANY HAS CORRECTED THIS PROB BY MANDATING THAT THE DOOR HAS 2 POS: OPEN, OR CLOSED AND LOCKED. ANOTHER CONTRIBUTING FACTOR APPEARS TO BE THAT NO ONE ON THE RAMP SEEMED TO BE SURE WHO'S RESPONSIBILITY IT WAS TO CLOSE THE DOOR. ALTHOUGH IT IS THE COMPANY'S POLICY THAT THE PERSON WHO MARSHALLS THE ACFT IS RESPONSIBLE FOR VERIFYING THAT THE CARGO DOOR IS CLOSED, IT DIDN'T SEEM TO ME THAT THE RAMP PERSONNEL PRESENT UNDERSTOOD THIS. ABOUT 10 MINS PRIOR TO THE FLT, I WAS IN THE R SEAT TO GET A CLRNC AND DO THE MANIFEST (WT AND BAL). THE CAPT WAS BUSY LOADING THE PAX. I BELIEVE THE CAPT SHUT THE CABIN DOOR WHILE THE RAMP PERSONNEL WERE STILL LOADING EXCESS CARRY-ON BAGGAGE IN THE REAR CARGO HOLD, AND THUS RELIED ON THE RAMP PERSONNEL TO CHK THAT THE CARGO DOOR WAS PROPERLY SECURED. THIS IS NORMAL PRACTICE, AND I WOULD CONSIDER IT TO HAVE BEEN UNUSUAL IF THE CAPT HAD DELAYED THE FLT BY PERSONALLY CHKING THE SECURITY OF THE CARGO DOOR. THE CAPT PERFORMED ALL CHKLISTS, AS USUAL. THE CHKLISTS INCLUDE TESTING THE ANNUNCIATOR SYS, AND VERIFYING THAT THE CABIN DOOR AND CARGO DOOR ANNUNCIATORS ARE EXTINGUISHED. THE CAPT LATER CLAIMED THAT ALL ANNUNCIATORS CHKED PROPERLY (WITH THE EXCEPTION OF THE CABIN DOOR ANNUNCIATOR WHICH WAS INOP, AND WAS A DEFERRED MAINT DISCREPANCY PER THE ACFT'S MEL) AND THAT THE CARGO DOOR ANNUNCIATOR WAS EXTINGUISHED. I CAN'T VERIFY THAT THE ANNUNCIATORS TESTED PROPERLY, BECAUSE I WAS FINISHING THE MANIFEST WHILE THE CAPT PERFORMED THIS CHK, HOWEVER, ALL WARNING ANNUNCIATORS WERE EXTINGUISHED WHEN WE TAXIED. EVERYTHING WAS NORMAL UNTIL ABOUT 300 FT AGL ON DEP. AT THIS POINT THE AIRPLANE BEGAN TO SHUDDER, AND THE CABIN COCKPIT WAS FILLED WITH A LOUD, LOW-FREQ, THROBBING SOUND. MY FIRST REACTION WAS THAT THE ACFT HAD LOST PART OF A PROP OR THAT SOMETHING WAS WRONG WITH ONE OF THE ENGS. NOTHING ON THE ENG GAGES INDICATED ANY ENG TROUBLE. THE CAPT RETARDED THE PROPS, BUT THIS PRODUCED NO CHANGE IN THE VIBRATION PATTERN. NEXT, THE CAPT REACHED TO TEST THE ANNUNCIATORS -- WHICH WERE ALL EXTINGUISHED. AFTER HITTING THE TEST BUTTON, THE CARGO DOOR ANNUNCIATOR REMAINED ILLUMINATED. WE RETURNED FOR AN IMMEDIATE AND UNEVENTFUL LNDG, AND THE ACFT'S HANDLING CHARACTERISTICS (AS FAR AS I COULD TELL AS PNF) DID NOT SEEM TO BE ADVERSELY AFFECTED. THE ACFT RECEIVED MINOR DAMAGE TO THE CARGO DOOR HINGE, AND A DENT ALONG THE VERT STABILIZER, STRAKE, BUT WAS OTHERWISE OK. LATER, IN TAXIING THE ACFT TO THE MAINT HANGAR, THE CARGO DOOR ANNUNCIATOR AGAIN FAILED TO ILLUMINATE. THE CAPT WAS ABLE TO GET IT TO ILLUMINATE BY TOUCHING IT, LIGHTLY, WITH HIS HAND. THE ANNUNCIATORS ARE DEACTIVATED BY PRESSING AND RELEASING THE ANNUNCIATOR FACE. ONCE YOU DO THIS, THE FACE POPS OUT, THE ANNUNCIATOR IS DEACTIVATED, AND IF YOU PULL FURTHER, THE ANNUNCIATOR BULB ASSEMBLY COMES ALL THE WAY OUT, SO THAT YOU CAN CHANGE THE LIGHT BULB. APPARENTLY, THE CARGO DOOR ANNUNCIATOR WAS ONLY MAKING INTERMITTENT ELECTRICAL CONTACT. IN SUMMARY, THERE ARE SEVERAL FACTORS I BELIEVE LEAD TO THIS INCIDENT: THE UNSAFE PRACTICE OF LEAVING THE CARGO DOOR CLOSED, BUT UNLOCKED (SINCE CORRECTED). HUMAN PERFORMANCE: THERE SHOULD BE 1 PERSON RUNNING THE SHOW ON THERAMP FOR A PARTICULAR ACFT, AND NO DOUBT ABOUT WHO THAT PERSON IS, THAT PERSON SHOULD CHK THAT THE CARGO DOOR IS CLOSED PRIOR TO TAXI, AND SHOULD NOT DELEGATE THIS RESPONSIBILITY. THE PLT WHO IS LOADING THE PAX SHOULD VISUALLY CHK TO SEE THAT THE CARGO DOOR IS IN THE HORIZ (IE, LOCKED) POS PRIOR TO TAXI, AND BETTER YET, CHK THE DOOR HIM OR HERSELF, SINCE OUR RAMP PERSONNEL CANNOT BE TRUSTED. CHKING THE ANNUNCIATOR INTEGRITY IS CRITICAL, ALTHOUGH IN RARE CASES, IT IS POSSIBLE THAT THIS MAY NOT ENSURE THAT THE DOOR IS CLOSED. ANNUNCIATOR DESIGN: IT WOULD BE BETTER TO DESIGN THE ANNUNCIATORS SUCH THAT THEY CONTINUE TO MAKE ELECTRICAL CONTACT UNTIL THEY ARE PULLED ALL THE WAY OUT, INSTEAD OF ONLY MAKING ELECTRICAL CONTACT WHEN THEY ARE ALL THE WAY IN -- THIS WOULD REDUCE THE POTENTIAL FOR FALSE POSITIVES CAUSED BY ANNUNCIATORS THAT ARE NOT PROPERLY SEATED IN THEIR SOCKET.

Data retrieved from NASA's ASRS site as of July 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.