Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Rochester, New York 14616
Tuesady, March 23, 1993 6:50 EST
NTSB Narrative Summary Released at Completion of Accident
ACCORDING TO THE PILOT, AFTER THE MAIN CABIN DOOR WAS CLOSED BY RAMP PERSONNEL, HE HAD A DOOR AJAR WARNING LIGHT ON THE CAP PANEL. HE REPORTED HE HAD FLOWN THE SUBJECT AIRCRAFT FOR FOUR LEGS THE PREVIOUS DAY AND A SIMILAR SITUATION OCCURRED ON THREE OF THOSE LEGS, SO HE PULLED THE CIRCUIT BREAKER AND RESET IT AFTER 10 SECONDS. THE DOOR LIGHT WAS EXTINGUISHED, AND THE PILOTS PROCEEDED TO TAKEOFF. DURING THE CLIMB, WHILE PASSING THROUGH 4000 FEET ABOVE THE GROUND, A POPPING SOUND WAS HEARD FOLLOWED BY A RAPID DECOMPRESSION. THE PILOTS NOTED THAT THE MAIN CABIN DOOR WAS AJAR, BUT FOR SAFETY REASONS, THEY DID NOT GO TO INSPECT THE DOOR. THE PILOTS SLOWED THE AIRPLANE TO 130 KNOTS INDICATED AIRSPEED, AND AFTER LANDING, THEY NOTED THE DOOR HAD SEPARATED FROM THE AIRCRAFT. SEARCH EFFORTS WERE MADE AND THE DOOR WAS LOCATED IN A FIELD ALONG THE PATH OF THE FLIGHT. THE DOOR WAS FLOWN TO SCOTLAND FOR FURTHER EXAMINATION AT JETSTREAM AIRCRAFT LIMITED; HOWEVER, THE EXAMINATION DID NOT DISCLOSE EVIDENCE OF MECHANICAL MALFUNCTION.
NTSB Probable Cause Narrative
FAILURE OF THE MAIN CABIN DOOR TO BE ADEQUATELY SECURED FOR FLIGHT FOR AN UNKNOWN REAS0N.
Event Information
| Type of Event | Incident |
| Event Date | 3/23/1993 |
| Event Day of the Week | Tuesday |
| Time of Event | 650 |
| Event Time Zone | Eastern Standard Time |
| Event City | ROCHESTER |
| Event State | NEW YORK |
| Event Country | -- |
| Zipcode of the event site | 14616 |
| Event Date Year | 1993 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | -- |
| Weather Briefing Completeness | Unknown |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 650 Eastern Standard Time |
| Direction of event from weather observation facility (degrees) | 1 |
| Weather Observation Facility ID | ROC |
| Elevation of weather observation facility | 559 |
| Distance of event from weather observation facility (units?) | 1 |
| Time Zone of the weather observation | EST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 25000 |
| Lowest Non-Ceiling Height | 15000 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | Overcast |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 15 |
| Air Temperature at event time (in degrees celsius) | -3 |
| Dew Point at event time (in degress fahrenheit) | -7 |
| Wind Direction (degrees magnetic) | 90 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 8 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 2 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 5022 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Mar 23 1993 12:00AM |
| NTSB Notification Time | 915 |
| Fiche Number and/or location -used to find docket information | 51201 |
| Date of most recent change to record | Dec 11 2000 1:11PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N496UE |
| NTSB Number | BFO93IA057 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 135: Air Taxi & Commuter |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | Minor |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | BRITISH AEROSPACE |
| Aircraft Model | BAE3201 |
| Aircraft Series Identifier | BAE3201 |
| Aircraft Serial Number | 900 |
| Certified Max Gross Weight | 16204 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 21 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Mar 12 1993 12:00AM |
| Airframe hours since last inspection | 61 |
| Airframe Hours | 3144 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | ATLANTIC COAST AIRLINES |
| Aircraft Owner Street Address | 1 EXPORT DRIVE |
| Aircraft Owner City | STERLING |
| Aircraft Owner State | VA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 22170 |
| Operator is an individual? | -- |
| Operator Name | ATLANTIC COAST AIRLINES |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 1 EXPORT DRIVE |
| Operator City | STERLING |
| Operator State | VA |
| Operator Country | |
| Operator Zip code | 22170 |
| Operator Code | VTZA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | Unknown |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | BUF |
| Departure City | BUFFALO |
| Departure State | NY |
| Departure Country | |
| Departure Time | 629 |
| Departure Time Zone | EST |
| Destination Same as Local Flt | crash at destination city |
| Destination Airport Code | |
| Destination City | |
| Destination State | |
| Destination Country | |
| Specific Phase of Flight | Climb |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |