Chicago O'Hare, IL, USA
N417AW
Bombardier, Inc. CL-600-2B19
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.
HISTORY OF FLIGHT On May 31, 2005, at approximately 1938 Central Daylight Time (CDT), a flight attendant on board United Express flight 5533, operated by Air Wisconsin, a Bombardier CL600-2B19, N417AW, was ejected from the airplane's service door and sustained serious injury following the boarding of the airplane at Chicago O'Hare International Airport (ORD), Chicago, Illinois. The scheduled passenger flight was being operated under the provisions of Title 14 CFR Part 121 on an instrument flight plan and was en route to Allentown, Pennsylvania. The flight attendant sustained serious injuries; there were no injuries to the 2 flight crewmembers or 24 passengers. The airplane was parked at gate F6B and an external air conditioning cart was providing cooled air to the cabin when the accident occurred. The captain briefed the flight attendant, before boarding the airplane and again in the cockpit, that there was an air conditioning cart hooked up to the airplane to cool the cabin and that she must keep one door open. The flight attendant stated that after the passengers had boarded the airplane, she approached the cockpit and the captain asked her to shut the service door and the main cabin door, however, none of the other doors were open and the airplane began to pressurize. After shutting the doors she turned toward the galley and the captain asked her if she closed the service door. She responded, "Yes! Do you want it open?" and the captain stated, "GET THE DOOR OPEN." She bent down, held the service door assist handle with her left hand, and opened the door with her right hand. As she lifted the handle upward, the door exploded open and she was blown out of the airplane and onto the ground. The flight attendant sustained a fractured left shoulder. TRAINING and PROCEDURES Air Wisconsin flight crewmembers receive training regarding the operation and warnings associated with the use of the external air conditioning cart. The CL-65 flight recurrent training material and Flight Crew Manual warn: At least one door to the cabin must remain open when using an outside source such as an air conditioning cart. The ramp operators also receive training that the air conditioning cart can pressurize the cabin and to keep the passenger entry door or cargo door open to prevent pressurization of the cabin. Air Wisconsin flight attendants do not receive training regarding the operation of the air conditioning cart and its ability to pressurize the cabin unless one door remains open. AIR CONDITIONING CART AND AIRPLANE SYSTEM INFORMATION The air conditioning cart is diesel powered and uses an on/off switch to control the 1,500 cubic feet per minute of conditioned air (cooled or heated) to the cabin. The cart has no means of regulating the amount of pressurized conditioned air that it feeds to the cabin. Bombardier places two placards on the CL-65 airplane relating to the dangers of opening a door when an air conditioning cart is being used. The placard on the overhead console in the cockpit and a placard on the external fuselage skin above the ground air conditioning system port read: "Warning" when the low pressure air ground connection is used the main cabin door or avionics bay door must be open. This narrative was modified on April 23, 2007.
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.
Source: NTSB Aviation Accident Database
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