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Attributes | |
ACN | 574056 |
Time | |
Date | 200302 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ugn.tower |
Operator | common carrier : air taxi |
Make Model Name | King Air C90 E90 |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 5000 flight time type : 600 |
ASRS Report | 574056 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Cabin Crew Human Performance Company |
Primary Problem | Aircraft |
Situations | |
Publication | Flt Crew Ops Manual |
Narrative:
On sat/feb/03, I was PIC flying the 3RD leg of a four segment trip. I was assisted by an additional crew member. We landed at ZZZ approximately xa:00 pm local and after engine shutdown the first officer went aft to deplane the passenger. The first officer told me he could not get the door open. I rechecked the cabin press was 'zero' made sure the engine bleeds were 'off' and opened my pilot window. I went aft to make sure he was not forcing the handle. I used my flashlight to ensure no cables or FOD were jammed in the door seal. I used the emergency exit to get out and opened the door from the outside after unlocking it with my keys. The reason the door would not open was because I had inadvertently relocked the door after opening the door on the ramp at ZZZ1. I had been issued an aircraft door key the same day as the trip. Despite previous king air experience we never locked the aircraft on military ramps. In korea and japan. I debriefed by company and fellow pilot on my miscue. We discussed exactly what the key slot should look like for flight which is 'trail-center-aft'. In the future, I will check if the cabin door is unlocked after closing it by opening it again and reclosing it. Callback conversation with reporter revealed the following information: the reporter stated the airplane was parked on the ramp overnight with the aft entry door locked for security. The reporter said in the morning the door was unlocked with a key and the door opened and the key removed. The reporter stated the passengers boarded the airplane and the reporter closed the door from the inside and checked the door for being properly closed and latched. The reporter said on arrival a crew member attempted to open the aft entry door and found the door could not be opened. The reporter stated he inspected the door and found everything in order with no obvious defects to prevent opening. The reporter said he exited from the airplane using the emergency exit and tried the aft entry door and discovered the door was still locked, but then using the door key the door was opened. The reporter stated that when the door was opened in the morning and on removing the key from the door the lock remained in the lock mode and locked the door when closed prior to departure. The reporter said there are no exterior stripes or placards on the door to warn and alert anyone of this dangerous situation. The reporter stated this door cannot be opened from the interior of the aircraft when inadvertently locked from the outside using the key. The reporter said the chief pilot and company pilots were briefed on this situation and all displayed surprise and disbelief that this anomaly could exist. The reporter stated the company never had a procedure that prior to departure the door would be opened if closed and reclosed to insure door could be opened from the aircraft interior. The reporter stated this door lock a medeco was an after market lock installed on a supplemental type certificate or alteration form 337.
Original NASA ASRS Text
Title: A BEECH E-90 AFTER LNDG WAS UNABLE TO OPEN THE AFT ENTRY TO DEPLANE THE PASSENGERS. CAPT EXITED EMER AND UNLOCKED DOOR FROM OUTSIDE.
Narrative: ON SAT/FEB/03, I WAS PIC FLYING THE 3RD LEG OF A FOUR SEGMENT TRIP. I WAS ASSISTED BY AN ADDITIONAL CREW MEMBER. WE LANDED AT ZZZ APPROX XA:00 PM LOCAL AND AFTER ENG SHUTDOWN THE FO WENT AFT TO DEPLANE THE PAX. THE FO TOLD ME HE COULD NOT GET THE DOOR OPEN. I RECHECKED THE CABIN PRESS WAS 'ZERO' MADE SURE THE ENG BLEEDS WERE 'OFF' AND OPENED MY PLT WINDOW. I WENT AFT TO MAKE SURE HE WAS NOT FORCING THE HANDLE. I USED MY FLASHLIGHT TO ENSURE NO CABLES OR FOD WERE JAMMED IN THE DOOR SEAL. I USED THE EMER EXIT TO GET OUT AND OPENED THE DOOR FROM THE OUTSIDE AFTER UNLOCKING IT WITH MY KEYS. THE REASON THE DOOR WOULD NOT OPEN WAS BECAUSE I HAD INADVERTENTLY RELOCKED THE DOOR AFTER OPENING THE DOOR ON THE RAMP AT ZZZ1. I HAD BEEN ISSUED AN ACFT DOOR KEY THE SAME DAY AS THE TRIP. DESPITE PREVIOUS KING AIR EXPERIENCE WE NEVER LOCKED THE ACFT ON MILITARY RAMPS. IN KOREA AND JAPAN. I DEBRIEFED BY COMPANY AND FELLOW PLT ON MY MISCUE. WE DISCUSSED EXACTLY WHAT THE KEY SLOT SHOULD LOOK LIKE FOR FLT WHICH IS 'TRAIL-CENTER-AFT'. IN THE FUTURE, I WILL CHECK IF THE CABIN DOOR IS UNLOCKED AFTER CLOSING IT BY OPENING IT AGAIN AND RECLOSING IT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE AIRPLANE WAS PARKED ON THE RAMP OVERNIGHT WITH THE AFT ENTRY DOOR LOCKED FOR SECURITY. THE RPTR SAID IN THE MORNING THE DOOR WAS UNLOCKED WITH A KEY AND THE DOOR OPENED AND THE KEY REMOVED. THE RPTR STATED THE PASSENGERS BOARDED THE AIRPLANE AND THE RPTR CLOSED THE DOOR FROM THE INSIDE AND CHECKED THE DOOR FOR BEING PROPERLY CLOSED AND LATCHED. THE RPTR SAID ON ARR A CREW MEMBER ATTEMPTED TO OPEN THE AFT ENTRY DOOR AND FOUND THE DOOR COULD NOT BE OPENED. THE RPTR STATED HE INSPECTED THE DOOR AND FOUND EVERYTHING IN ORDER WITH NO OBVIOUS DEFECTS TO PREVENT OPENING. THE RPTR SAID HE EXITED FROM THE AIRPLANE USING THE EMER EXIT AND TRIED THE AFT ENTRY DOOR AND DISCOVERED THE DOOR WAS STILL LOCKED, BUT THEN USING THE DOOR KEY THE DOOR WAS OPENED. THE RPTR STATED THAT WHEN THE DOOR WAS OPENED IN THE MORNING AND ON REMOVING THE KEY FROM THE DOOR THE LOCK REMAINED IN THE LOCK MODE AND LOCKED THE DOOR WHEN CLOSED PRIOR TO DEP. THE RPTR SAID THERE ARE NO EXTERIOR STRIPES OR PLACARDS ON THE DOOR TO WARN AND ALERT ANYONE OF THIS DANGEROUS SIT. THE RPTR STATED THIS DOOR CANNOT BE OPENED FROM THE INTERIOR OF THE ACFT WHEN INADVERTENTLY LOCKED FROM THE OUTSIDE USING THE KEY. THE RPTR SAID THE CHIEF PLT AND COMPANY PLTS WERE BRIEFED ON THIS SIT AND ALL DISPLAYED SURPRISE AND DISBELIEF THAT THIS ANOMALY COULD EXIST. THE RPTR STATED THE COMPANY NEVER HAD A PROC THAT PRIOR TO DEP THE DOOR WOULD BE OPENED IF CLOSED AND RECLOSED TO INSURE DOOR COULD BE OPENED FROM THE ACFT INTERIOR. THE RPTR STATED THIS DOOR LOCK A MEDECO WAS AN AFTER MARKET LOCK INSTALLED ON A SUPPLEMENTAL TYPE CERTIFICATE OR ALTERATION FORM 337.
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.