SEA92LA029
1991-10-28 · BILLINGS, Montana, United States · None · 1 aircraft · Status: Completed
Aircraft involved
Probable cause & findings
THE UNLATCHING AND SUBSEQUENT OPENING INFLIGHT OF THE LEFT-REAR ENGINE COWL DOOR. A FACTOR CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF COMPANY MAINTENANCE PERSONNEL TO EXECUTE THE MANUFACTURER'S SERVICE BULLETIN.
Factual narrative
SHORTLY AFTER THE COMPANY INITIATED ABORT OF THE MEDEVAC FLIGHT, THE FLIGHT CREW OF THE AEROSPATIALE AS355 FELT A SHUDDER WHICH THEY ATTRIBUTED TO GUSTY WIND CONDITIONS. UPON LANDING AT BILLINGS INTERNATIONAL AIRPORT, MONTANA, A PORTION OF THE LEFT-REAR ENGINE COWL DOOR WAS FOUND TO BE SEPARATED, ALONG WITH DAMAGE TO THE MAIN ROTOR BLADES NECESSITATING REPLACEMENT OF THE BLADES. THE CREW HAD PREVIOUSLY NOTIFIED COMPANY PERSONNEL OF THE COWL DOOR LATCH PROBLEM AND HAD PREFLIGHTED THE COWL PRIOR TO THE ACCIDENT FLIGHT. THE MANUFACTURER WAS AWARE OF THE PROBLEM AND HAD ISSUED A RELEVANT SERVICE BULLETIN. THE SERVICE BULLETIN HAD NOT BEEN IMPLEMENTED ON THE ACCIDENT AIRCRAFT. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1991_SEA92LA029.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA) From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- Semantic Scholar 2025 · Article (Applied Sciences) Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…