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The new 'fortress door' on a B737-300 comes open on takeoff when the first officer fails to activate the correct locking mechanism before takeoff at lax, ca.
| Attributes | |
| ACN | 557312 |
| Time | |
| Date | 200208 |
| Day | Sun |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : lax.airport |
| State Reference | CA |
| Altitude | agl bound lower : 0 agl bound upper : 5000 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B737-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : takeoff roll |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 165 flight time total : 4200 flight time type : 1306 |
| ASRS Report | 557312 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : company policies non adherence : far other anomaly other |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | flight crew : overcame equipment problem other |
| Consequence | other |
| Supplementary | |
| Problem Areas | Company FAA Flight Crew Human Performance Aircraft |
| Primary Problem | Flight Crew Human Performance |
Narrative:
First officer mistook emergency exit slide pin for manual door lock on new fortress door. On takeoff roll, cockpit door swung open. At a safe altitude, we locked the door using the manual lock. Note: first time using new door with electrical lock disarmed. Callback conversation with reporter revealed the following information: there are 2 locking system aside from the old electrically controled latch which was deactivated after sep/tue because of unstated problems. That switch is located on the center pedestal. The emergency exit sliding pins (4) are located on each of the 4 corners of the door. Their function is to hold the door panels in place. In case of an emergency, the pins can be slid open and the panels then kicked out for exiting the cockpit. These are a new addition. The manual door lock is a round shaped lock that is located on the upper right portion of the door. This is also a new addition. That is supposed to be locked after the manual bar is dropped in place. The flight was running late and the first officer assumed the slide pin was the lock. The crew had no training on the door and failed to refer to the diagrams of the door. After the door opened on takeoff the flight attendant sitting forward cabin jump seat closed the door. The crew locked the door at about 5000 ft.
Original NASA ASRS Text
Title: THE NEW 'FORTRESS DOOR' ON A B737-300 COMES OPEN ON TKOF WHEN THE FO FAILS TO ACTIVATE THE CORRECT LOCKING MECHANISM BEFORE TKOF AT LAX, CA.
Narrative: FO MISTOOK EMER EXIT SLIDE PIN FOR MANUAL DOOR LOCK ON NEW FORTRESS DOOR. ON TKOF ROLL, COCKPIT DOOR SWUNG OPEN. AT A SAFE ALT, WE LOCKED THE DOOR USING THE MANUAL LOCK. NOTE: FIRST TIME USING NEW DOOR WITH ELECTRICAL LOCK DISARMED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THERE ARE 2 LOCKING SYS ASIDE FROM THE OLD ELECTRICALLY CTLED LATCH WHICH WAS DEACTIVATED AFTER SEP/TUE BECAUSE OF UNSTATED PROBS. THAT SWITCH IS LOCATED ON THE CTR PEDESTAL. THE EMER EXIT SLIDING PINS (4) ARE LOCATED ON EACH OF THE 4 CORNERS OF THE DOOR. THEIR FUNCTION IS TO HOLD THE DOOR PANELS IN PLACE. IN CASE OF AN EMER, THE PINS CAN BE SLID OPEN AND THE PANELS THEN KICKED OUT FOR EXITING THE COCKPIT. THESE ARE A NEW ADDITION. THE MANUAL DOOR LOCK IS A ROUND SHAPED LOCK THAT IS LOCATED ON THE UPPER R PORTION OF THE DOOR. THIS IS ALSO A NEW ADDITION. THAT IS SUPPOSED TO BE LOCKED AFTER THE MANUAL BAR IS DROPPED IN PLACE. THE FLT WAS RUNNING LATE AND THE FO ASSUMED THE SLIDE PIN WAS THE LOCK. THE CREW HAD NO TRAINING ON THE DOOR AND FAILED TO REFER TO THE DIAGRAMS OF THE DOOR. AFTER THE DOOR OPENED ON TKOF THE FLT ATTENDANT SITTING FORWARD CABIN JUMP SEAT CLOSED THE DOOR. THE CREW LOCKED THE DOOR AT ABOUT 5000 FT.
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.