Synopsis
Eagle Air Flight NZ2854 was a scheduled service from Auckland to Whangarei, operating on the 9th of April 2010. Just after lifting off, the aircrafts rear cargo door opened in flight, the end result of a number of latent and active errors which had been introduced to the operation by parties involved.
The above picture shows an Eagle Air Beech 1900D and the cargo door in the open position.
Incident Causes
The Transport Accident Investigation Commission report into the incident details a number of errors and events leading up to the incident. A breakdown of these is as follows.
Latent Errors
- A known and existing fault with the Cargo door unsafe sensor prevented this system from being relied upon on this aircraft. A red warning light on the Flight Deck would normally provide an indication the door was not secure however, as this system was defective, the crew (as expected) ignored the warning light.
- The cargo door handle rigging was approaching its limits. Instead of simply rotating the handle to the locked position, a certain amount of ‘wiggle’ would have been required to ensure the poppet locks engaged.
- A button with a brightly coloured orange neck which ‘popped’ out when the locks were engaged correctly had faded over time. It was therefore not necessarily obvious to an observer whether the locks had engaged correctly.
Active Errors
- The failure of the First Officer to correctly complete his walk around and comply with the company requirement and that of the deferral log to visually inspect and confirm the closure of the cargo door. This was the final element which then saw the aircraft depart and experience sufficient movement on takeoff for the cargo door to spring open.
Conclusion
Neither crew perceived the Threat the cargo door presented to the aircraft. As the TAIC identified, if the crew had, they would likely have paid more attention to this element and put in place stronger safe guards and prevented the incident. The First Officer probably intended to check the security of the door but became distracted during his walkaround. The incident is a fairly good example of Reason’s Accident Causation (or ‘Swiss Cheese’) model and shows how various factors can combine to produce a potentially negative outcome. Some factors were outside of the crew’s control. For example, the company elected to ‘defer’ the failed cargo door warning system instead of grounding the aircraft. The most significant change as a result of this incident is that in future situations where the Cargo door unsafe warning system is not functioning, both pilots are required to check the security of the cargo door.
Want to know more?
TAIC REPORT: Cargo Door open in flight
