Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On the evening of 18 January 2018, a Diamond DA42 aircraft departed from Parafield Airport, South Australia (SA) on an IFR dual training flight.
At about 2104 Central Daylight-saving Time (CDT), the aircraft was maintaining 3,200 ft, 5 NM north-west of Parafield Airport when the crew received a DOOR OPEN annunciator on the primary flight display. The crew checked and secured the front canopy and observed the rear door to be in the unlocked position. With the student pilot flying, the instructor attempted to latch the rear door. During the attempt, the rear door opened abruptly and detached from the aircraft. The instructor took over control and conducted a return to Parafield Airport, SA.
It was determined that the crew omitted to check and secure the door in the pre-flight inspection, the before-start checks and the hold point checks. The door was observed to be closed and down; however, it was unlatched and therefore not secured.
The aircraft flight manual (AFM) (Figure 1) in-flight emergency procedure when a door opens, advises to reduce speed and land at the nearest aerodrome. The crew did not reference the AFM and attempted to shut the door in-flight resulting in the door opening and subsequently detaching from the aircraft.
The operator conducted a search, but was unable to locate the door.
Source: Diamond Aircraft Industries Inc.
A search of the ATSB database revealed a similar occurrence:
On the afternoon of 14 October 2014, the pilot/owner of an amateur-built Van’s Aircraft Inc. RV-6A aircraft, registered VH-JON and operated in the ‘experimental’ category, departed Moorabbin Airport, Victoria on a local flight.
Shortly after reaching a cruise altitude of 2,900 ft, the aircraft descended to 2,500 ft. After that time, no further air traffic control radar returns were received from the aircraft. The aircraft descended rapidly and a witness reported observing objects falling from the aircraft. The aircraft subsequently collided with the ground next to a house in the suburb of Chelsea, 8 km south of Moorabbin. The pilot was fatally injured and the aircraft was destroyed.
Following the accident, members of the public found a number of aviation-related items away from the accident site that belonged to the pilot.
The liberation of the items from the aircraft’s interior indicated that the canopy likely opened in‑flight. However, this was based on the assumption that the items were initially inside the cabin.
It was possible that the pilot was startled and distracted after the canopy opened due to the severe cockpit wind, noise and debris flying about. Though, the extent to which this contributed to the occurrence was unknown.
Also, while the ATSB was unable to determine how the canopy opening would have affected aircraft control, there were indications that the pilot was attempting to respond to the situation. However, for reasons undetermined, recovery did not occur.
As a result of this occurrence, the operator has advised the ATSB that they are taking the following safety actions:
The Head of Operations issued an email reminding crew of the correct procedures of obtaining a visual confirmation of the door being latched and secured, and when a door becomes open in flight.
This occurrence serves as a reminder for pilots to check the security of their aircraft’s doors prior to departure. When a door opens mid-flight the risks can result in distraction, damage to the aircraft, personal injury, and if it becomes detached; damage or injury on the ground. The incident also highlights the importance of referencing the flight manual during emergency procedures.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
- Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft to operate in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC conditions while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements.
|Date:||18 January 2018||Investigation status:||Completed|
|Location:||9 km NW of Parafield|
|Release Date:||15 May 2018||Occurrence category:||Serious Incident|
|Report status:||Final||Highest injury level:||None|
|Aircraft manufacturer||Diamond Aircraft Industries|
|Type of operation||Flying Training|
|Damage to aircraft||Minor|