Mode of transport
Occurrence ID
AB-2023-004
Occurrence date
Report release date
Occurrence category
Aviation occurrence type
Location
Fraser Island
State
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.

What happened

On 6 April 2023 at about 16:15 local time, a GippsAero GA8 Airvan aircraft took off from an aeroplane landing area near Eli Creek on Fraser Island, Queensland, for a 30-minute scenic flight. On board were the pilot, a second pilot flying as a passenger in the right cockpit seat, and 2 passengers.

At about 16:40, while in a climb Northeast of Lake Wabby, the rear cabin door separated and fell from the aircraft. The pilot immediately flew toward the nearest aeroplane landing area on Seventy-Five Mile beach, north of Eurong Township, and landed without incident. The pilot and passengers were not injured. The door was not recovered.

Door departure history

There have been several reported instances of a cargo door departure in flight with the GA8 aircraft. Initial investigations indicated that excessive wear of the forward cargo door slide could have been a contributing factor. Further investigations identified that over rotation of the door handle may also lead to the door opening in flight.

GippsAero advised that the typical failure mode involves the front door slider disconnecting from its track, the front of the door popping outward, and airflow peeling the door off the side of the aircraft.

Service Bulletin

CASA Airworthiness Directive AD/GA8/3 Amendment 2 mandated compliance with Gipps-Aero Service Bulletin SB-GA8-2005-23, issue 3. Service Bulletin SB-GA8-2005-23 issue 3 introduced the mandatory modification to the cargo door guide assembly, and requirement for periodic cabin door inspections, for all GA8 and GA8-TC 320 aircraft.

SB-GA8-2005-23 issues 4 to 6 specify the mandatory requirement for inspection of the door operating rod and mechanism, replacement of the door handle with an integrated stop added, and embodiment of a centre cargo door rail aft stop modification.

Safety action

Other company GA8 aircraft were inspected prior to return to service with no abnormal wear reported. The company is working with GippsAero and revisiting all relevant Service Bulletins and Airworthiness Directives to help determine the cause of the failure and prevent a reoccurrence.

Safety message

Operators of GippsAero GA8 and GA8-TC 320 aircraft are reminded of the requirement to regularly inspect the cargo door slides and rails for excessive wear in accordance with CASA AD/GA8/3 Amendment 2 and SB-GA8-2005-23 issue 3.

GippsAero further recommends that SB-GA8-2005-23 issue 6 inspections are carried out, and the door rail stop is installed, and the latch modifications embodied, to increase reliability and safety of the door latch mechanism and reduce the likelihood of a recurrence of a door departing 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.

Aircraft Details
Departure point
Eli Creek ALA, Fraser Island
Destination
Eli Creek ALA, Fraser Island
Model
GA8
Sector
Piston
Operation type
Part 135 Air transport operations - smaller aeroplanes
Damage
Minor
Manufacturer
GippsAero