SAFETY INVESTIGATION REPORT CABIN DOOR OPEN IN FLIGHT

Transcription

1 SAFETY MANAGEMENT OFFICE September 2014 Brussels South Charleroi Airport Building S7 Rue des Fusillés, 1 B-6041 Gosselies SAFETY INVESTIGATION REPORT CABIN DOOR OPEN IN FLIGHT Aircraft: PIPER PA CHEROKEE ARCHER II Incident location: EBCI Airport Type of flight: VFR Phase: Takeoff Persons on board: Pilot in command and 2 passengers

2 I. CONTENT I. Content. II. Introduction. III.Summary. IV.Constatations - Analyse. 1.Medium 2.Machine 3.Management 4.Man V. Conclusions. VI.Recommendations. VII.Glossary. 1

3 II. INTRODUCTION The sole objective of the investigation of the incident that happened to the PA Cherokee Archer II shall be to promote accident and incident prevention. It is not the purpose of this activity to apportion blame or liability. (ICAO Annex 13) This investigation was carried out in order to: Better understand the events leading up to the incident; Identify hazards and conduct risk assessments; Make recommendations to reduce or eliminate unacceptable risks; and Communicate the safety messages to the appropriate stakeholders. The investigation was conducted by Didier Buzin, ATO Safety Manager. Regulation (EU) No 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investigation and prevention of accidents and incidents in civil aviation and repealing Directive 94/56/EC Conduct of Safety Investigations Every accident or serious incident involving aircraft other than those specified in Annex II to Regulation (EC) No 216/2008 shall be the subject of a safety investigation. Safety investigation authorities may decide to investigate also other accidents, serious incidents or incidents when they expect to draw safety lessons from them. Communication of Information Article 15 of the Regulation stipulates that: the anonymity of those involved in an accident or incident shall be protected; information, deemed relevant to the prevention of accidents and incident, shall be communicated to aircraft (and equipment) manufacturers, maintenance organizations, aircraft operators and training organizations; EASA and national civil aviation authorities receive relevant factual information obtained during the safety investigation, except information referred to in Article 14(1); The Investigation Report Each safety investigation shall be concluded with a report in a form appropriate to the type and seriousness of the accident or serious incident without apportioning blame or liability. The report shall protect the anonymity of any individual involved in the accident or serious incident. Safety Recommendations and follow-up Safety recommendations may contain any preventive actions considered necessary to enhance aviation safety. A safety recommendation shall in no case create a presumption of blame or liability for an accident, serious incident or incident. 2

4 III. Summary Upon takeoff at Brussels South (EBCI), and soon after liftoff, the cabin door of the PA Cherokee Archer II went open for about 30 degrees. The front seat passenger immediately tried to close the door in flight, helped by the pilot in command (PIC), without success. PIC brought directly his aircraft to downwind position, in order to land as soon as possible. After landing, PIC closed the door properly and taxied in for another takeoff. IV. Observations-Analyse 1. Medium a) Weather Not applicable b) Terrain Runway 25 in use 2. Machine a) Technical state prior incident Defect report doesn t show any discrepancies regarding the cabin door POH, Section 4 - Normal procedures, 4.9 Preflight Check, states: Upon entering the aircraft, ( ) close and secure the cabin door and check that all the required papers are in order and in the airplane. b) Technical analyze POH, Section 2 - Limitations, 2.23 Placards, states: Adjacent to upper door latch: ENGAGE LATCH BEFORE FLIGHT Upper door latch 3

5 In full view of the pilot, one of the following takeoff checklists and the following landing check list will be installed: POH, Section 4 - Normal Procedures, Normal Procedures Check list Preflight, states: POH, Section 4 - Normal Procedures, Normal Procedures Check list Before Takeoff, states: 4

6 POH, Section 4 - Normal Procedures, 4.21 Before Takeoff, states: All doors should be properly secured and latched. c) Particular inquiries or Analyzes i. There are no placards foreseen in the POH regarding side latch position. Side latch (open) ii. With regard to the mishap aircraft, it exists some friction between the fuselage and the cabin door. A certain amount of force is required to settle the cabin door in closed position. This might generate in some circumstances a wrong feeling of having the door in the correct closed position. In some particular case, it s even possible to set the side latch on close while having the cabin door partially open. Fuselage side Upper door side Side latch (closed) Side lock (closed) Side lock 5

7 iii. With regard to the mishap aircraft, the upper latch is working as intended. Upper latch closed Upper latch open Upper lock d) Partial conclusions i. The absence of side latch placards might lead to confusion as for latch operation. ii. POH, Section 4 - Normal Procedures, Normal Procedures Check list Before Takeoff, states «Doors latched». There is no differentiation between side and upper latch. iii. The friction between the fuselage and the cabin door prevents the smooth operation of the latter. 3. Management a) ATO s management i. Two (2) flights were required to qualify PIC on PIPER PA CHEROKEE ARCHER II. Restriction is stipulated in the flight log: Qualification PA28 satisfactory Restricted runway 1000m. ii. PIC didn t operate the cabin door inside the cockpit, prior the event flight (Flight Instructor did). PIC never noticed there was an upper latch to close (not only the side latch). iii. PIC didn t know that POH contains emergency procedure dealing with open door procedure. iv. The event flight is the third one flown on PA POB = 3 destination EBNM (Temploux) this airfield operates on grass runways - RWY 06L/24R (630mx50m) & RWY 06R/24L (695m x 31m) recommended for motorized planes (RWY 24L: right-hand circuit). 6

8 b) Flight preparation i. PIC uses ATO s flight check list and a personnel check list too. c) Flight i. PIC didn t give any safety briefing to his passengers. ii. PIC does not recollect having verified the correct cabin door s latching. d) Incident i. Soon after liftoff, the cabin door opened. Instantaneously PIC tried to close it while maintaining aircraft control, without success. The front seat passenger made an unsuccessful trial too. e) Immediate events after incident i. PIC entered directly downwind position without warning ATC. ii. ATC gave traffic avoidance to another aircraft being on downwind at the same time. iii. After explaining the issue to ATC, PIC performed a precautionary landing. iv. After landing, PIC latched the door (upper and side latch), and taxied in for another takeoff. 7

9 Here below the communications between PIC and Tower during the incident: Traffic avoidance given to a conflicting traffic on downwind Regulation UTC (EU) : ATC No 996/2010 : "OOJCM report on final" Protection UTC of Sensitive : Pilot : "Report Safety Information on final JCM" Article 14 UTC: of the ATC Regulation : "OOJCM establishes wind calm a list cleared of records to land that runway shall 25" not be made available UTC or used : Pilot for : purposes "Cleared other to land than 25 OCM, safety cleared investigation, to land" such as written or electronic UTC : recordings ATC : "OOJCM and transcriptions vacate left S3 contact of recordings ground on from 121.8" air traffic control units; UTC : Pilot : "S3 ground 121.3, correct JCM" No more communications related to the incident are to be noted. e) Partial conclusions i. PIC didn t completely apply procedures imposed by POH: POH Section 3- Emergency procedures 3.27 Open Door, states: To close the door in flight, slow the airplane to 87 KIAS, close the cabin vents and open the storm window. If the top latch is open, latch it. If the side latch is open, pull on the armrest while moving the latch handle to the latched position; If both latches are open, close the side latch then top latch. POH Section 3- Emergency procedures 3.3 Emergency procedure checklist, states: ii. iii. The lack of communication and the use of non-standard communication between PIC and ATC, led to an airborne conflicting situation. The lack of POH knowledge led to incorrect cabin door latching. 8

10 4. Man a) Pilot In Command (MP) i. MP s qualification LICENSE PPL (A) VALIDITY OK ii. MP s medical certificate ii. MP s recent experience : CLASS VALIDITY 2 OK Pilot s total flying hours - 103:47 Hrs b) Passengers i. Human factors Front seat passenger unstrapped himself to have more freedom to close the cabin door while being airborne. He was rapidly asked by PIC not to do so. c) Partial conclusions i. Nobody was injured in the incident. ii. PIC had no solid experience on the PA iii. PIC didn t give an appropriate safety briefing to his passengers. iv. PIC s flight log doesn t reflect his landing at EBNM the day of event. 9

11 V. CONCLUSIONS Foreword: This file is drafted in soul and consciousness based on the total of the available data. Any idea of fault or responsibility was excluded. The aim of this investigation is to discover the causes and the contributory factors which led to the incident, with as purpose to describe recommendations thus a similar incident does not occur anymore. The Safety Manager must be prepared to reopen/complete the investigation, if its content gives the opportunity to be disputed, worth knowing if solid arguments can support this. Cause: The situation or the act which caused the accident. Contributive factor: Situation or act which played a role in the development of the circumstances which led to the accident/incident. Non contributive anomaly: situation or act which did not play role in the development of the circumstances which led to the accident/incident but considered as potential danger. Fact: neutral determination of a situation or an act. Machine 01 Cabin door of Mishap Aircraft doesn t close as expected. Contributive factor 02 POH Section 4- normal procedures do not make the distinction between upper and side latch, it only states close and secure the cabin door or All doors should be properly secured and latched. Non contributive anomaly 03 Absence of side latch placards. Contributive factor Management 04 Upon testimony, PIC never operated cabin door inside the cockpit prior the event flight. Contributive factor 05 Upon testimony, PIC partially covered the aircraft s POH during his PA qualification Cause 06 ATO s aircraft check list does not exactly reflect POH procedures. Fact 07 The lack of communication and the use of non-standard communication between PIC and ATC led to ambiguities. Fact Man 08 Despite the advice of Chief Flight Instructor to perform a solo flight, PIC scheduled his third flight on PA , with passengers. Fact 09 Contrary to flight log restriction, PIC operated PA on runway <1000m as from fourth flight. Fact 10

12 VI. Recommendations Foreword: The following recommendations were drafted based on the situation at the time of the incident. New ATO s procedures are already studied in order to improve flight supervision. R001 (Ref conclusion N 01) Actions have to be taken on technical side to position the cabin door thus there is no more friction between the fuselage and the cabin door. Field of expertise: Belgian Flight Maintenance. R002 (Ref conclusion N 02) POH Section 4- normal procedures should make the distinction between side and upper latch. Wording might be close and secure the cabin door with the side latch and the upper latch. POH Section 4-normal procedures check list should state: Upper Door Latch.. Closed and Side Door Latch.. Closed. Field of expertise: Safety Manager, Piper Aircraft Corporation. R003 (Ref conclusion N 03) Placard adjacent to side latch should be added in order to indicate the correct Open/Close position. A POH amendment should reflect this recommendation too. Field of expertise: Safety Manager, Piper Aircraft Corporation. R004 (Ref conclusion N 04) Flight Instructors should allow the pilot under training/qualification operate the cabin door from inside the cockpit. Field of expertise: Chief Flight Instructor, Safety Manager. R005 (Ref conclusion N 05) Thorough POH knowledge is paramount prior operating an aircraft. A special attention has to be done regarding pilot community education. Field of expertise: Chief Flight Instructor, Chief Theoretical Knowledge Instructor, Safety Manager. R006 (Ref conclusion N 06) ATO s aircraft check list has to be amended thus it follows POH procedure Field of expertise: Chief Flight Instructor, Safety Manager. R007 (Ref conclusion N 07) Radio transmission might lead to safety issue if standard communication is not used. A special attention has to be done regarding pilot community education. Field of expertise: Chief Flight Instructor, Chief Theoretical Knowledge Instructor, Safety Manager. R008 (Ref conclusion N 08) A Safety Card should be available to help passenger understanding PIC safety briefing (see example on page 13) Field of expertise: Chief Flight Instructor, Safety Manager. 11

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14 VII. Glossary ATC ATO EBCI ICAO PIC POH Air Traffic Controller Approved Training Organization ICAO code of Brussels South airport International Civil Aviation Organization Pilot In Command Pilot s Operating Handbook 13