NTSB Identification: ATL91IA044.
The docket is stored on NTSB microfiche number 44257.
Scheduled 14 CFR
Incident occurred Thursday, January 31, 1991 in CHARLOTTE, NC
Probable Cause Approval Date: 05/05/1993
Aircraft: BRITISH AEROSPACE BAE JETSTREAM 3201, registration: N844AE
Injuries: 5 Uninjured.

NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.

AFTER THE NO. 2 ENGINE STARTED, THE FLIGHT CREW NOTICED A CABIN DOOR OPEN LIGHT. THE CAPTAIN SHUT DOWN THE NO. 1 ENGINE, AND SIGNALED TO THE GROUND CREW TO CHECK THE DOOR. THE CAPTAIN RECYCLED THE DOOR WARNING CIRCUIT BREAKER SEVERAL TIMES, AND THE LIGHT EXTINGUISHED. ON CLIMBOUT, PASSING 7,000 FEET, THE CABIN DOOR SUDDENLY SEPARATED FROM THE AIRPLANE. THE FLIGHT RETURNED TO THE DEPARTURE AIRPORT AND LANDED WITHOUT FURTHER PROBLEMS. THE INVESTIGATION REVEALED THAT THE GROUND CREW DID NOT UNDERSTAND THE CAPTAIN'S INTENTIONS, AND DID NOT CHECK THE DOOR FOR SECURITY. THE CAPTAIN DID NOT FOLLOW CHECKLIST PROCEDURES FOR DEALING WITH A DOOR LIGHT ON THE GROUND. THE RAMP AGENT, THE LAST PERSON TO CLOSE THE DOOR, HAD NOT OPERATED JETSTREAM DOORS PRIOR TO THE DAY OF THE INCIDENT. EXAMINATION OF THE AIRCRAFT AND THE RECOVERED DOOR REVEALED NO EVIDENCE OF MALFUNCTION OR FAILURE.

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

THE FAILURE OF THE CAPTAIN TO FOLLOW CHECKLIST PROCEDURES, RESULTING IN A FLIGHT WITH THE CABIN DOOR UNSECURED, AND THE SUBSEQUENT LOSS OF THE CABIN DOOR.

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