Individually Owned: 151,845
Corporate Owned: 143,699
Chicago O'hare International Airport
Aircraft Accident/Incident Report
Chicago O'hare, Illinois
Tuesady, May 31, 2005 19:38 CDT
NTSB Narrative Summary Released at Completion of Accident
While the flight crew was preparing the aircraft for flight, the flight attendant opened the service door and was ejected onto the tarmac and seriously injured. At the time of the accident, the airplane was being cooled by an external diesel powered air conditioning cart that pressurizes the cabin when the airplane doors are closed. The external air conditioning cart was required because the auxiliary power unit was inoperative. The captain said that he briefed the flight attendant, before boarding the airplane and again in the cockpit, to keep one door open. The captain did not specify that the reason the flight attendant needed to keep a door open was because the air conditioning cart pressurized the cabin if all the doors were closed. After passenger boarding was completed the flight attendant stated she approached the cockpit and the captain asked her to close the main cabin door and the service door. She closed the service door, and crossed the galley and closed the main cabin door. Right afterward, the captain felt the pressure rise in his ears and yelled "GET THE DOOR OPEN." The flight attendant approached the service door and bent down, held the service door assist handle with her left hand and opened the service door with her right hand. As the service door unlatched it forcefully opened and ejected the flight attendant onto the ground. Although the flight crewmembers and ramp operators receive training regarding the operation and warnings of pressurizing the cabin when the air conditioning cart is hooked up to the airplane, the flight attendants do not receive any training on the operation and warnings for the external air conditioning cart. The airplane has two placards warning to keep a door open when the air conditioning cart is hooked up to the airplane. One placard is on the overhead console in the cockpit and the other is outside of the cabin on the fuselage skin directly above the connection for the external air conditioning cart.
NTSB Probable Cause Narrative
The opening of the service door when the airplane was pressurized. Contributing to the accident was the captain's failure to ensure that one of the airplane doors was open while a ground-cooling cart was connected, which resulted in pressurizing the airplane on the ground.
Event Information
| Type of Event | Accident |
| Event Date | 5/31/2005 |
| Event Day of the Week | Tuesday |
| Time of Event | 1938 |
| Event Time Zone | Central Daylight Time |
| Event City | Chicago O'Hare |
| Event State | ILLINOIS |
| Event Country | -- |
| Zipcode of the event site | -- |
| Event Date Year | 2005 |
| Event Date Month | 5 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | -- |
| Event Location Longitude | -- |
| Event Location Airport | Chicago O'Hare International |
| Event Location Nearest Airport ID | ORD |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 668 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Unknown |
| Time of the weather observation | |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | ORD |
| Elevation of weather observation facility | 668 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | CDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | -- |
| Sky Condition for Lowest Ceiling | -- |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | -- |
| Air Temperature at event time (in degrees celsius) | -- |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | -- |
| Wind Speed (knots) | -- |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Serious |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 26 |
| Injury Total Serious | 1 |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 21398 |
| NTSB Notification Source | Passenger onboard the flight |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Apr 25 2007 2:54PM |
| User who most recently changed record | NTSB\lema |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N417AW |
| NTSB Number | DCA05MA071 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | No |
| Damage | Minor |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Bombardier, Inc. |
| Aircraft Model | CL-600-2B19 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 7610 |
| Certified Max Gross Weight | 51000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 54 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | -- |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | -- |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | US Bank NA Trustee |
| Aircraft Owner Street Address | Corporate Trust Services |
| Aircraft Owner City | Boston |
| Aircraft Owner State | MA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | -- |
| Operator is an individual? | No |
| Operator Name | Air Wisconsin Airlines Corporation |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | W6390 Challenger Drive, Suite 203 |
| Operator City | Appleton |
| Operator State | WI |
| Operator Country | USA |
| Operator Zip code | 54914 |
| Operator Code | A6WA |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| 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) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | ORD |
| Departure City | Chicago O'Hare |
| Departure State | IL |
| Departure Country | USA |
| Departure Time | -- |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | ABE |
| Destination City | Allentown |
| Destination State | PA |
| Destination Country | USA |
| Specific Phase of Flight | Standing - pre-flight |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Mar 30 2007 9:22AM |
| User who most recently changed record | DELI |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |