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|
Attributes | |
ACN | 450845 |
Time | |
Date | 199909 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | Marginal |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : atl.tower tower : phx.tower |
Operator | common carrier : air carrier |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure : other published ifr departure |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 260 flight time total : 5500 flight time type : 4000 |
ASRS Report | 450845 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : landed in emergency condition other |
Consequence | other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Aircraft Maintenance Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Shortly after XA00, flight departed atl bound for mcn. Immediately after takeoff, very strong and loud vibrations forced us to return for immediate landing. It was found that the cargo door had been left open. Shortly after boarding, prior to the flight, I checked the maintenance log and deferral log. We found that the cargo door indication light had been deferred. As was customary, I advised the first officer shortly before departure to inspect the fuel panel doors, but also to include the cargo door in his last min check. This was done approximately 5 mins before departure. About 3 mins before departure, the ramp agent who loaded our airplane handed us the paperwork to complete the load manifest form. It seemed reasonable to assume the person loading our airplane would also serve as a 'double-check' to the status of our cargo door, and that after all bags had been loaded and the quantity of bags verified, that the ramp agent would make sure the cargo door was closed. The first officer again verbally verified to me that the cargo door was closed immediately prior to engine start. We later discovered that ramp agent's original count of the bags was terribly inaccurate. Stating, originally, that we had 5 checked bags only, we found that we truly had 2 checked bags, 1 carry-on bag, 2 pounds of cargo and 5 pounds of company mail. This pointed to 1 of 2 possibilities. Either extra cargo was added without the ramp agent's knowledge, or the ramper's irresponsibility and lack of accuracy in counting bags led to a last min breakdown in safety. We later continued the flight to mcn with no further problems.
Original NASA ASRS Text
Title: AN EMB120 IS MANDATED TO RETURN LAND AFTER SEVERE VIBRATIONS ARE FELT AFTER TKOF FROM ATL, GA.
Narrative: SHORTLY AFTER XA00, FLT DEPARTED ATL BOUND FOR MCN. IMMEDIATELY AFTER TKOF, VERY STRONG AND LOUD VIBRATIONS FORCED US TO RETURN FOR IMMEDIATE LNDG. IT WAS FOUND THAT THE CARGO DOOR HAD BEEN LEFT OPEN. SHORTLY AFTER BOARDING, PRIOR TO THE FLT, I CHKED THE MAINT LOG AND DEFERRAL LOG. WE FOUND THAT THE CARGO DOOR INDICATION LIGHT HAD BEEN DEFERRED. AS WAS CUSTOMARY, I ADVISED THE FO SHORTLY BEFORE DEP TO INSPECT THE FUEL PANEL DOORS, BUT ALSO TO INCLUDE THE CARGO DOOR IN HIS LAST MIN CHK. THIS WAS DONE APPROX 5 MINS BEFORE DEP. ABOUT 3 MINS BEFORE DEP, THE RAMP AGENT WHO LOADED OUR AIRPLANE HANDED US THE PAPERWORK TO COMPLETE THE LOAD MANIFEST FORM. IT SEEMED REASONABLE TO ASSUME THE PERSON LOADING OUR AIRPLANE WOULD ALSO SERVE AS A 'DOUBLE-CHK' TO THE STATUS OF OUR CARGO DOOR, AND THAT AFTER ALL BAGS HAD BEEN LOADED AND THE QUANTITY OF BAGS VERIFIED, THAT THE RAMP AGENT WOULD MAKE SURE THE CARGO DOOR WAS CLOSED. THE FO AGAIN VERBALLY VERIFIED TO ME THAT THE CARGO DOOR WAS CLOSED IMMEDIATELY PRIOR TO ENG START. WE LATER DISCOVERED THAT RAMP AGENT'S ORIGINAL COUNT OF THE BAGS WAS TERRIBLY INACCURATE. STATING, ORIGINALLY, THAT WE HAD 5 CHKED BAGS ONLY, WE FOUND THAT WE TRULY HAD 2 CHKED BAGS, 1 CARRY-ON BAG, 2 LBS OF CARGO AND 5 LBS OF COMPANY MAIL. THIS POINTED TO 1 OF 2 POSSIBILITIES. EITHER EXTRA CARGO WAS ADDED WITHOUT THE RAMP AGENT'S KNOWLEDGE, OR THE RAMPER'S IRRESPONSIBILITY AND LACK OF ACCURACY IN COUNTING BAGS LED TO A LAST MIN BREAKDOWN IN SAFETY. WE LATER CONTINUED THE FLT TO MCN WITH NO FURTHER PROBS.
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.