Investigation Summary
Shortly after takeoff, the flight crew noticed the cargo door had opened. While attempting to return for an emergency landing, the aircraft's aerodynamic characteristics were severely compromised by the open door. The investigation revealed that the cargo door had been improperly latched before departure. The NTSB highlighted that the external lockpin manual control handle was not properly marked, and the door-open warning system was inadequate. Furthermore, McDonnell Douglas had not provided specific flightcrew guidance or emergency procedures for handling an in-flight cargo door opening on the DC-9, leaving the pilots to manage an unprecedented aerodynamic failure.
Final Conclusions
The National Transportation Safety Board determined the probable cause was the loss of control of the airplane for undetermined reasons following the in-flight opening of the improperly latched cargo door. Contributing factors included inadequate preflight verification procedures, poor marking of the door handle, lack of manufacturer guidance for door-open emergencies, and the FAA's failure to mandate modifications to the warning system despite previous known occurrences.
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Main Cargo Door
The large forward door used for loading freight, which failed to remain locked due to improper latching.
Door Warning System
The electrical circuit designed to alert pilots if the door is not secure; it was found to be inadequate in this configuration.
Lockpin Control Handle
The external manual handle used to secure the door, which lacked proper markings to indicate a locked status.
Interesting Facts
- 01The aircraft was a freighter conversion of the DC-9-33.
- 02Night visual meteorological conditions (VMC) existed at the time of the crash.
- 03The cargo door was found to have been improperly latched due to a failure in preflight verification.
- 04Both the Captain and First Officer were killed in the impact.
- 05The NTSB cited a lack of emergency procedures for this specific failure in the DC-9 flight manual.
Safety Actions & Advisories
Cargo Door Marking Requirements
The NTSB recommended that the FAA require clear external markings on DC-9 cargo door handles to visually confirm the lockpin position.
Warning System Modification
Recommendations were made to mandate modifications to the door-open warning system to ensure reliability on cargo-configured DC-9s.
Emergency Procedure Development
McDonnell Douglas was urged to provide specific flightcrew guidance for handling the aerodynamic effects of an open cargo door.