Narrative:

I was preparing to conduct a flight. In preparation for the flight; my copilot attached the crew ladder to the side of the airplane beneath the crew cabin access hatch. (The 3 rung ladder has 3 upside-down u-shaped hooks that slide down over metal buttons riveted to the side of the fuselage and it is held in place primarily by gravity.) my copilot placed the thin gray braided nylon rope over the hatch threshold at the aft corner of that opening instead of placing it over the forward corner and hooking the loop at the end of the hatch release handle on the inside of the airplane. Color; thickness; and placement of the rope were all factors leading to the incident about to be described. When we were all loaded with cargo and ready to go; we climbed up into the airplane and sat down at our stations. I shut the crew hatch down; latched it (feeling no resistance as I did) and called for the preflight and prestart checklists; which my copilot recited from the hard copy checklists provided in the airplane. One item on the checklist was the checking of proper latching of the crew hatch; so; at that point I slid the pilot's seat back; pulled out my flashlight; shined it into each of the viewing holes in the top of the threshold; and verified that each latch had indeed hooked over its corresponding pin (in the hatch itself). I never noticed the rope over the threshold as it was behind my left shoulder when my seat was full aft. At this point we believed that we were ready to taxi; called for and received taxi clearance; and started our flight. We departed and flew into turbulence at 12000 ft MSL in the vicinity of the mountains to the west. It was in this area where we heard a 'thud' which we both thought was a cargo tray falling off of a stack behind us and onto the cabin floor. When we arrived at destination; I opened the crew door and realized the true source of the thud. The ladder was not behind the pilot's seat and only the frayed end of the broken rope remained outside. I observed a dent in the leading edge of the left horizontal stabilizer; the obvious result of the ladder parting from the hooks on the side of the airplane. This event occurred; of course; because we didn't pull the ladder inside the aircraft; but certain important operational factors contributed to its occurrence. First; 2 nights later during a flight by the assistant chief pilot and the same copilot; it was discovered that the checklist in a different airplane in the fleet did not include a preflight checklist item for stowing the crew ladder. Upon returning to the hangar in which our aircraft was being stored; the assistant chief pilot asked my copilot to climb into the aircraft and look at the checklist. He did; and he discovered that the checklist in that airplane was missing the same item. (I have been told in the last 3 days since the accident that most of the airplanes in the fleet had checklists with the item mentioning the stowing of the crew ladder; but 3; including ours; did not. Second; as I have since pointed out to my superiors; the rope attached to the ladder was different than other ropes on other airplanes in the fleet (where those other airplanes even have ropes attached to the ladders) in that it was of insufficient diameter to prevent the hatch from fully closing and latching and that it was of a color that was difficult to see in a dark cockpit. (The color would optimally be bright yellow.) third; the placement of the rope over the threshold and that the loop at its end wasn't hooked over the hatch release handle inside the cockpit were both factors in my not recognizing that the ladder was still outside the aircraft. The first and second factors above point to problems of standardization in equipment and documentation. These I have pointed out to my immediate superiors (chief pilot and assistant chief pilot). Additionally; as I have also pointed out to these individuals; no one can be expected to remember everything that must be done for each flight 100% of the time; especially given the hours at night that we work; how often we work; the schedule pressures under which we work; in the varying and adverse WX conditions we undertake flight; and in the airplanes available to us; each having its own idiosyncrasies to deal with. I said that sometimes we will forget certain items however important they might be; and that the availability and use of complete; standardized checklists should preclude those items from not being executed.

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Original NASA ASRS Text

Title: FLT CREW OF BE99 FAIL TO STOW ENTRY LADDER BEFORE TKOF. LOSE LADDER ENRTE; CAUSING MINOR DAMAGE TO STABILIZER.

Narrative: I WAS PREPARING TO CONDUCT A FLT. IN PREPARATION FOR THE FLT; MY COPLT ATTACHED THE CREW LADDER TO THE SIDE OF THE AIRPLANE BENEATH THE CREW CABIN ACCESS HATCH. (THE 3 RUNG LADDER HAS 3 UPSIDE-DOWN U-SHAPED HOOKS THAT SLIDE DOWN OVER METAL BUTTONS RIVETED TO THE SIDE OF THE FUSELAGE AND IT IS HELD IN PLACE PRIMARILY BY GRAVITY.) MY COPLT PLACED THE THIN GRAY BRAIDED NYLON ROPE OVER THE HATCH THRESHOLD AT THE AFT CORNER OF THAT OPENING INSTEAD OF PLACING IT OVER THE FORWARD CORNER AND HOOKING THE LOOP AT THE END OF THE HATCH RELEASE HANDLE ON THE INSIDE OF THE AIRPLANE. COLOR; THICKNESS; AND PLACEMENT OF THE ROPE WERE ALL FACTORS LEADING TO THE INCIDENT ABOUT TO BE DESCRIBED. WHEN WE WERE ALL LOADED WITH CARGO AND READY TO GO; WE CLBED UP INTO THE AIRPLANE AND SAT DOWN AT OUR STATIONS. I SHUT THE CREW HATCH DOWN; LATCHED IT (FEELING NO RESISTANCE AS I DID) AND CALLED FOR THE PREFLT AND PRESTART CHKLISTS; WHICH MY COPLT RECITED FROM THE HARD COPY CHKLISTS PROVIDED IN THE AIRPLANE. ONE ITEM ON THE CHKLIST WAS THE CHKING OF PROPER LATCHING OF THE CREW HATCH; SO; AT THAT POINT I SLID THE PLT'S SEAT BACK; PULLED OUT MY FLASHLIGHT; SHINED IT INTO EACH OF THE VIEWING HOLES IN THE TOP OF THE THRESHOLD; AND VERIFIED THAT EACH LATCH HAD INDEED HOOKED OVER ITS CORRESPONDING PIN (IN THE HATCH ITSELF). I NEVER NOTICED THE ROPE OVER THE THRESHOLD AS IT WAS BEHIND MY L SHOULDER WHEN MY SEAT WAS FULL AFT. AT THIS POINT WE BELIEVED THAT WE WERE READY TO TAXI; CALLED FOR AND RECEIVED TAXI CLRNC; AND STARTED OUR FLT. WE DEPARTED AND FLEW INTO TURB AT 12000 FT MSL IN THE VICINITY OF THE MOUNTAINS TO THE W. IT WAS IN THIS AREA WHERE WE HEARD A 'THUD' WHICH WE BOTH THOUGHT WAS A CARGO TRAY FALLING OFF OF A STACK BEHIND US AND ONTO THE CABIN FLOOR. WHEN WE ARRIVED AT DEST; I OPENED THE CREW DOOR AND REALIZED THE TRUE SOURCE OF THE THUD. THE LADDER WAS NOT BEHIND THE PLT'S SEAT AND ONLY THE FRAYED END OF THE BROKEN ROPE REMAINED OUTSIDE. I OBSERVED A DENT IN THE LEADING EDGE OF THE L HORIZ STABILIZER; THE OBVIOUS RESULT OF THE LADDER PARTING FROM THE HOOKS ON THE SIDE OF THE AIRPLANE. THIS EVENT OCCURRED; OF COURSE; BECAUSE WE DIDN'T PULL THE LADDER INSIDE THE ACFT; BUT CERTAIN IMPORTANT OPERATIONAL FACTORS CONTRIBUTED TO ITS OCCURRENCE. FIRST; 2 NIGHTS LATER DURING A FLT BY THE ASSISTANT CHIEF PLT AND THE SAME COPLT; IT WAS DISCOVERED THAT THE CHKLIST IN A DIFFERENT AIRPLANE IN THE FLEET DID NOT INCLUDE A PREFLT CHKLIST ITEM FOR STOWING THE CREW LADDER. UPON RETURNING TO THE HANGAR IN WHICH OUR ACFT WAS BEING STORED; THE ASSISTANT CHIEF PLT ASKED MY COPLT TO CLB INTO THE ACFT AND LOOK AT THE CHKLIST. HE DID; AND HE DISCOVERED THAT THE CHKLIST IN THAT AIRPLANE WAS MISSING THE SAME ITEM. (I HAVE BEEN TOLD IN THE LAST 3 DAYS SINCE THE ACCIDENT THAT MOST OF THE AIRPLANES IN THE FLEET HAD CHKLISTS WITH THE ITEM MENTIONING THE STOWING OF THE CREW LADDER; BUT 3; INCLUDING OURS; DID NOT. SECOND; AS I HAVE SINCE POINTED OUT TO MY SUPERIORS; THE ROPE ATTACHED TO THE LADDER WAS DIFFERENT THAN OTHER ROPES ON OTHER AIRPLANES IN THE FLEET (WHERE THOSE OTHER AIRPLANES EVEN HAVE ROPES ATTACHED TO THE LADDERS) IN THAT IT WAS OF INSUFFICIENT DIAMETER TO PREVENT THE HATCH FROM FULLY CLOSING AND LATCHING AND THAT IT WAS OF A COLOR THAT WAS DIFFICULT TO SEE IN A DARK COCKPIT. (THE COLOR WOULD OPTIMALLY BE BRIGHT YELLOW.) THIRD; THE PLACEMENT OF THE ROPE OVER THE THRESHOLD AND THAT THE LOOP AT ITS END WASN'T HOOKED OVER THE HATCH RELEASE HANDLE INSIDE THE COCKPIT WERE BOTH FACTORS IN MY NOT RECOGNIZING THAT THE LADDER WAS STILL OUTSIDE THE ACFT. THE FIRST AND SECOND FACTORS ABOVE POINT TO PROBS OF STANDARDIZATION IN EQUIP AND DOCUMENTATION. THESE I HAVE POINTED OUT TO MY IMMEDIATE SUPERIORS (CHIEF PLT AND ASSISTANT CHIEF PLT). ADDITIONALLY; AS I HAVE ALSO POINTED OUT TO THESE INDIVIDUALS; NO ONE CAN BE EXPECTED TO REMEMBER EVERYTHING THAT MUST BE DONE FOR EACH FLT 100% OF THE TIME; ESPECIALLY GIVEN THE HRS AT NIGHT THAT WE WORK; HOW OFTEN WE WORK; THE SCHEDULE PRESSURES UNDER WHICH WE WORK; IN THE VARYING AND ADVERSE WX CONDITIONS WE UNDERTAKE FLT; AND IN THE AIRPLANES AVAILABLE TO US; EACH HAVING ITS OWN IDIOSYNCRASIES TO DEAL WITH. I SAID THAT SOMETIMES WE WILL FORGET CERTAIN ITEMS HOWEVER IMPORTANT THEY MIGHT BE; AND THAT THE AVAILABILITY AND USE OF COMPLETE; STANDARDIZED CHKLISTS SHOULD PRECLUDE THOSE ITEMS FROM NOT BEING EXECUTED.

Data retrieved from NASA's ASRS site as of January 2009 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.