Output Number
Approval Date
Published Date Time
Recommendation type
Mode
Date released
Background Text



On 7 September 2004, at about 0710 Eastern Standard Time, while
passing FL175, during a gradual descent from flight level (FL) 220,
the pilot of the Raytheon B300 aircraft, registered VH-KJD, heard a
loud muffled thud and then air noise. The pilot saw that the cabin
door had separated from the aircraft fuselage.



The aircraft was being operated as a single pilot, private IFR
flight, from Brisbane to Truganinni, Queensland. A 'safety pilot'
occupied the right pilot seat. During the occurrence, the cabin
door warning light illuminated and the cabin oxygen masks deployed.
The pilots completed emergency checks and actions before diverting
the aircraft to Thangool, Queensland.



On 12 September, the cabin door was found in a paddock
approximately 3 NM north of Glenbar, Queensland (see Figure 1). The
pilot reported that the wind at FL170 was from the south-west at 40
knots.



The investigation found that the aft door latch hook sense switch
terminal screw and the sense switch adjustment nut were located in
very close proximity (see Figure 2). The manufacturer uses the term
'sense switch' for the electrical switches attached to each of the
cabin door locks. These switches provide an indication to the
cockpit annunciator panel of the door lock positions.



A circuit test of the three sense switches, located within the
door (two switches for the two latch hooks and the other for the
door handle position) determined that it was possible for the aft
latch hook sense switch to produce an earth point through the sense
switch earth loop wiring, resulting in the door handle position
sense switch no longer providing an electrical signal for its
position. Consequently, one of the systems to alert a pilot to a
potential cabin door unsafe condition was not available.



The crew reported that during the flight there had been no warning
annunciator panel indication prior to the door opening. The aft
latch hook sense switch mounting plate showed no significant
distortion and there was no evidence of in-service movement of the
aft latch hook sense switch adjustment mechanism.



The investigation is continuing and is examining several aspects
in relation to the cabin door separation, including the mechanical
locking mechanism of the door.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil
Aviation Safety Authority advise operators of Beechcraft King Air
and Raytheon King Air aircraft of the potential safety deficiency
of the cabin door warning system becoming prematurely earthed,
resulting in a sense switch or switches no longer providing an
electrical signal for its or their position.



The recommendation was simultaneously issued as R20040075 to the
US Federal Aviation Administration.

ATSB comment:

In response to ATSB Recommendation R20040074 issued on 25
October 2004, CASA issued AWB31-3 issue 1 on 10 February 2005 to
address the sense switch problem.

Organisation Response
Date Received
Organisation
Civil Aviation Safety Authority
Response Text

CASA has drafted an Airworthiness Bulletin (AWB) to be sent to
all operators of the aircraft highlighting the issue of proximity
of the switch and its contact with the airframe.



The AWB is currently awaiting approval and CASA undertakes to
inform the ATSB when the AWB is released.



ATSB Comment: On 10 February 2005 CASA issued AWB31-3 issue 1 to
address the sense switch problem.

ATSB Response date