View of right front passenger door with emergency exit placard
View of right rear passenger door latch in up/closed position
View of fuselage damage on right side
View of internal damage of fuselage on right side
Aviation Accident Final Report - National Transportation Safety Board
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Fresno, California
Federal Aviation Administration / Flight Standards District Office; Fresno, California
Investigation Docket - National Transportation Safety Board:
Accident Number: GAA19CA372
Date & Time: 04/29/2019, 1401 PDT
Registration: N189JC
Aircraft: Cessna T206
Aircraft Damage: Substantial
Defining Event: Miscellaneous/other
Injuries: 2 None
Flight Conducted Under: Public Aircraft
Analysis
The pilot reported that, during the preflight inspection and after a passenger had entered the airplane, he ensured that the rear cargo portion of the right cabin door, which also had a forward passenger portion adjacent to the second row of passenger seats, was secure. After completing the preflight inspection, the pilot entered the airplane and saw the passenger close and latch the forward portion of the right door. He then saw the passenger, who was seated in the right, rear passenger seat, struggling with the seatbelt, which passed between the seat and the right cargo door. The pilot suggested that the passenger switch seats, and the passenger moved to the left, rear passenger seat and fastened his seatbelt.
The pilot reported that, during the flight, while maneuvering and descending to 1,600 ft mean sea level, he banked left and then heard a "brief whistle," followed by a "loud boom." He looked behind him and saw that both portions of the right cabin door were open. He returned to the departure airport without further incident.
The airplane sustained substantial damage to the fuselage.
Postaccident examination of the airplane revealed red paint transfer marks on the forward portion of the door from the rear portion door latch, and both door sections could be opened if the latch for the rear door was open. The pilot reported that he believed that the right, rear passenger seatbelt "must have pulled on the [rear] door latch enough to dislodge it." He added that the red paint transfer mark was not there before the flight.
The pilot provided a postaccident examination video, which showed that he was able to use the larger airbag section of the seatbelt to wedge open the rear cargo door latch.
The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to verify that the rear cargo portion of the right cabin door was adequately secured before flight, which resulted in both portions of the door opening in flight and substantial damage to the fuselage.
Findings
Aircraft Passenger/crew doors - Inadequate inspection
Personnel issues Preflight inspection - Pilot
Factual Information
History of Flight
Prior to flight Aircraft inspection event
Maneuvering Miscellaneous/other (Defining event)
Certificate: Commercial; Private
Age: 32, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 03/07/2019
Occupational Pilot: Yes
Last Flight Review or Equivalent: 06/29/2017
Flight Time: (Estimated) 1246 hours (Total, all aircraft), 402 hours (Total, this make and model), 1128 hours (Pilot In Command, all aircraft), 150 hours (Last 90 days, all aircraft), 39 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N189JC
Model/Series: T206 H
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: T20609510
Landing Gear Type: Tricycle
Seats: 3
Date/Type of Last Inspection: 04/08/2019, Annual
Certified Max Gross Wt.: 3789 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 741.3 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: C126 installed, not activated
Engine Model/Series: TIO-540-AJ1A
Registered Owner: Tulare County Sheriff
Rated Power: 310 hp
Operator: Tulare County Sheriff
Operating Certificate(s) Held: None
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KPTV, 442 ft msl
Distance from Accident Site: 12 Nautical Miles
Observation Time: 2056 UTC
Direction from Accident Site: 59°
Lowest Cloud Condition:
Visibility: 10 Miles
Lowest Ceiling: Broken / 4900 ft agl
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 260°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.77 inches Hg
Temperature/Dew Point: 25°C / 11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Porterville, CA (PTV)
Type of Flight Plan Filed: None
Destination: Porterville, CA (PTV)
Type of Clearance: None
Departure Time: 1242 PDT
Type of Airspace: Class E
Wreckage and Impact Information
Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 35.927222, -119.271944 (est)
No comments:
Post a Comment