Page, AZ, USA
N261GL
Raytheon Aircraft Company 1900D
The scheduled air carrier was departing from an airport. During taxi, cockpit voice recorder data indicated that the first officer was stating and verifying the checklists, as well as taxiing the airplane. Company standard operating procedures required that those checklists be called out by one crewmember and verified by the other. The flight crew spoke of personal matters and did not follow the sterile cockpit regulations as specified by 14 Code of Federal Regulations Part 21.542. The captain stated that during takeoff, the cargo door light illuminated, the aft cargo door opened, and the flight crew returned to land at the airport. According to the airplane manufacturer, if the door is not closed and locked, a cockpit light will illuminate indicating that the door is not secure. Following the accident, operation of the door and functionality of the cockpit indicator light were verified. The cargo door indicator light is to be checked by both crewmembers on the Before Takeoff checklist. Due to the flight crew’s lack of professionalism and deviation from standard operating procedures, they most likely did not see that the light was illuminated prior to departure.
HISTORY OF FLIGHT On March 26, 2008, at 1220 mountain standard time, a Hawker Beechcraft Corporation 1900D, N261GL, operating as Great Lakes Airlines (GLA) flight 5187, made an emergency landing at Page Municipal Airport, Page, Arizona, due to an open cargo door during takeoff. Great Lakes Aviation Limited was operating the airplane under the provisions of 14 Code of Federal Regulations Part 121. The captain, first officer, and 11 passengers were not injured. The airplane sustained minor damage. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight was destined for Four Corners Regional Airport, Farmington, New Mexico. According to the Director of Safety for the airline, just after takeoff, the cargo door opened. The flight crew returned uneventfully to the airport and landed. The flight crew indicated that the cargo door light was not illuminated prior to departure. In the captain's written statement, he reported that 5 to 10 seconds after rotation he noticed the illumination of the cargo door annunciator light. He indicated that before he could reach for the emergency checklist it became clear that the cargo door opened due to the increase in noise. The captain transferred the controls from the first officer and landed the airplane uneventfully. PERSONNEL INFORMATION The captain held an airline transport pilot certificate with single engine and multi-engine land, instrument airplane ratings. The captain also held a first class medical certificate dated November 2007. The medical certificate listed no restrictions or limitations. The company reported the captain as having 3,000 total flying hours, 2,228 hours in the Beech 1900, and 258 hours within the previous 90 days. The captain had successfully completed a company line check ride on June 3, 2007. The first officer held a commercial pilot certificate with single engine and multi-engine land, instrument airplane ratings. The first officer held a first class medical certificate dated October 2006. The medical certificate had a limitation for wearing corrective lenses. The company reported the first officer as having 2,190 total flying hours, 1,085 hours in the Beech 1900, and 200 hours within the previous 90 days. The first officer successfully completed a company line check ride on September 27, 2007. AIRCRAFT INFORMATION The airplane was a Hawker Beechcraft Corporation 1900D, serial number UE-261, twin engine turboprop-powered airplane with a carrying capacity of 2 flight crewmembers, 19 passengers, and baggage. The airplane was manufactured in 1996 and registered to Great Lakes Aviation, Limited, Cheyenne, Wyoming. The airplane is maintained under a Federal Aviation Administration (FAA) approved continuous airworthiness program. A routine continuous airworthiness inspection was performed on March 23, 2008, with an airframe time of 24,065.5 hours. The aft cargo door is located on the left side of the airplane. If the door is not closed and locked, a cockpit light will illuminate indicating that the door is not secure. Following the accident, operation of the door and functionality of the cockpit indicator light were verified. No anomalies were noted. FLIGHT RECORDERS The airplane was equipped with a Cockpit Voice Recorder (CVR) and a Digital Flight Data Recorder (DFDR). Both recorders were removed from the airplane shortly after the incident, and were shipped to the National Transportation Safety Board's Vehicle Recorder Division in Washington, DC, for readout. A CVR Group was formed and the group reviewed the tape recording and developed a CVR transcript. In summary, the recording indicated that as the flight crew went through their checklists, they made comments and jokes about a variety of topics. The checklist items were interspersed with the personal comments. The first officer taxied the airplane as well as briefed the checklist, and the captain commented about the first officer’s control of the airplane during taxi. Approximately 7 seconds after reaching a takeoff safety speed (V2), the sound of increased wind noise was heard through the microphone channel. The flight then returned to land at the departure airport. TESTS AND RESEARCH Safety Board investigators interviewed management personnel regarding the incident. In summary, they indicated that the flight crew had no prior problems or discipline during their employment at the airline. The captain had been employed as a captain for 2 years, and the first officer had been employed by the airline for 2 years. The standard operating procedures specify that the taxi checklist be called out by one crewmember, and verified by the other. GLA management indicated that although the captain will normally taxi the airplane, this item could be delegated to the first officer. Management personnel indicated that the crew acted unprofessionally prior to the cargo door coming open through their lack of professionalism and failure to act in accordance with standard operating procedures. They were not aware of any similar events. As a result of the incident, a bulletin was released to all flight crew personnel to stress the importance of sterile cockpits and professionalism. ADDITIONAL INFORMATION The 14 Code of Federal Regulations Part 121.542 indicates, in part, the following: "(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft. (c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight." According to Section 3.4.1, Exterior Inspection, of the GLA Flight Standards Manual for the Beech 1900D, the cargo compartment, cargo door annunciator circuitry check, and cargo door security and closure should be completed prior to engine start. Additionally, section 3.4.12, Before Takeoff, indicates that all annunciators should be considered and this item is to be verified by both crewmembers.
The flight crew’s unprofessional behavior and deviation from standard operating procedures which resulted in an in-flight emergency.
Source: NTSB Aviation Accident Database
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