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Atlas / NTSB / ATL91IA044

NTSB CAROL · Event

Event ATL91IA044

1991-01-31 CHARLOTTE, North Carolina, United States Airport · CLT None 1 aircraft Status: Completed

Aircraft involved

Probable cause & findings

THE FAILURE OF THE CAPTAIN TO FOLLOW CHECKLIST PROCEDURES, RESULTING IN A FLIGHT WITH THE CABIN DOOR UNSECURED, AND THE SUBSEQUENT LOSS OF THE CABIN DOOR.

Factual narrative

AFTER THE NO. 2 ENGINE STARTED, THE FLIGHT CREW NOTICED A CABIN DOOR OPEN LIGHT. THE CAPTAIN SHUT DOWN THE NO. 1 ENGINE, AND SIGNALED TO THE GROUND CREW TO CHECK THE DOOR. THE CAPTAIN RECYCLED THE DOOR WARNING CIRCUIT BREAKER SEVERAL TIMES, AND THE LIGHT EXTINGUISHED. ON CLIMBOUT, PASSING 7,000 FEET, THE CABIN DOOR SUDDENLY SEPARATED FROM THE AIRPLANE. THE FLIGHT RETURNED TO THE DEPARTURE AIRPORT AND LANDED WITHOUT FURTHER PROBLEMS. THE INVESTIGATION REVEALED THAT THE GROUND CREW DID NOT UNDERSTAND THE CAPTAIN'S INTENTIONS, AND DID NOT CHECK THE DOOR FOR SECURITY. THE CAPTAIN DID NOT FOLLOW CHECKLIST PROCEDURES FOR DEALING WITH A DOOR LIGHT ON THE GROUND. THE RAMP AGENT, THE LAST PERSON TO CLOSE THE DOOR, HAD NOT OPERATED JETSTREAM DOORS PRIOR TO THE DAY OF THE INCIDENT. EXAMINATION OF THE AIRCRAFT AND THE RECOVERED DOOR REVEALED NO EVIDENCE OF MALFUNCTION OR FAILURE. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12

Verbatim from NTSB's published report. Source file NTSB_1991_ATL91IA044.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.