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 21 November 2018, a Gippsland GA-8 was operating a charter flight with one pilot and six passengers on board, at Fraser Island, Queensland (Qld).
During the flight on the return to Eli Creek, Qld, at 1520 Eastern Standard Time, the aircraft encountered turbulent conditions at 2,000 feet and the forward cargo door opened. As the pilot conducted a right turn, the door detached from the aircraft.
Post-flight, after the passengers disembarked, the aircraft was inspected. The inspection revealed damage to the rear latch receptacle indicating the door was only partially latched. It is suspected that the door was not correctly secured prior to take-off and that during the turbulent conditions a passenger may have inadvertently unlatched it.
There was an Airworthiness Directive (AD/GA8/3) released in 2005 by the Civil Aviation Safety Authority (CASA), and then amended in 2010, advising operators of the GA-8 that excessive wear in the forward cargo door slide may result in the door becoming detached from the aircraft in flight. The operator had been aware of this and had inspected the door a month prior to the event. No defects were found at the time of the inspection.
This occurrence highlights the importance of flight crew ensuring the doors have been correctly secured during the pre-flight checks. Failure to do so could result in the door opening in-flight and objects falling form the aircraft with the potential to cause damage or injury.
Independent research by Transport Canada has found that the two main potential causes for doors opening on piston engine aircraft, have been due to the door being incorrectly closed and excessive wear of the locking mechanism.
It is recommended by CASA in an Airworthiness Bulletin for inadvertent opening of doors in flight that operators and maintainers take the following action:
- Ensure that all aircraft openings “doors and hatches” are inspected to ensure that:
- the wear of the locking mechanisms are within limits
- the door or hatch locks with a positive action
- the aircraft doors still meet the original type certification design.
- Maintenance personnel completing periodic inspections should ensure that all placards detailing door operating instructions are present and clearly visible both internally and external on the aircraft.
- Operators are to ensure that:
- the flight crew are made aware of the requirement to confirm that all doors and hatches are secured correctly prior to the starting of engines
- the passengers are briefed correctly in the operation of doors particularly on aircraft types where a passenger is sitting at the only access door to the aircraft.
- It is recommended that operators train flight crew on the appropriate procedures to follow in the event of a door opening in flight.
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.
|Date:||21 November 2018||Investigation status:||Completed|
|Location:||4km North East of Eli Creek|
|Release Date:||21 December 2018||Occurrence category:||Incident|
|Report status:||Final||Highest injury level:||None|
|Aircraft manufacturer||Gippsland Aeronautics Pty Ltd|
|Type of operation||Charter|
|Damage to aircraft||Minor|
|Departure point||Fraser Island, Qld|
|Destination||Eli Creek, Qld|