N440AM

HISTORY OF FLIGHT

On July 9, 1995, at 2109 central daylight time, an ATR 72-212, N440AM, operated by Simmons Airlines, as American Eagle Flight 4127 (Eagle 127), experienced a loss of the rear cabin entry door during climb after taking off on runway 4L from the O'Hare International Airport, Chicago, Illinois. The airplane received minor damage to the door structure and aircraft fuselage. One flight attendant received minor injuries. The cockpit flight crew, 1 flight attendant and 61 passengers reported no injuries. Following the door separation, the flight which was bound for South Bend, Indiana, returned to O'Hare International Airport, and landed without incident.

At 2036:40, Eagle 127 requested and received an IFR clearance for the flight to South Bend, Indiana. At 2058:42, Eagle 127 was instructed to taxi to runway 4L. Eagle was cleared into position and hold on runway 4L at 2107:21. This was followed by a takeoff clearance at 2107:53 with the instruction to fly heading 060 after takeoff. At 2109:44, Eagle 127 requested to return to the airport for an immediate landing. At 2110:12, Eagle 127 was instructed to make a left teardrop turn back to runway 22R. During the turn back to the runway at 2111:12 Eagle 127 requested to have the emergency equipment standing by. At 2112:48, Eagle 127 was cleared to land on runway 22R. Eagle 127 landed uneventfully and at 2115:44, while taxiing to the penalty box, the crew stated to the Inbound Ground Controller that they had a door come open in flight.

The emergency equipment followed Eagle 127 to the penalty box. The #1 flight attendant was removed from the airplane and transferred to a local hospital. The passengers were deplaned by use of a ladder and were bused to the terminal area.

INJURIES TO PERSONS

There were no injuries reported by the 60 ticketed passengers on board the airplane. In addition there was one in- lap infant who was also not injured. The 2 cockpit crewmembers and the #2 flight attendant were not injured.

The #1 flight attendant was transported to Resurrection Medical Center by a Chicago Fire Department E.M.S. Unit. She was treated for multiple contusions and abrasions to her left hand and forearm. She also stated that her right leg and arm were sore. This Flight Attendant stated she received these injuries when she threw herself forward onto the floor in an attempt to get away from the open door. She stated she hit her arm on a galley cart and the floor.

DAMAGE TO AIRCRAFT

Several areas of the outer skin on the separated door were compressed. Two vertical intercostals within the door were buckled. Minor damage occurred to the aircraft fuselage. See Structures Group Chairman Report for further details.

PERSONNEL INFORMATION

Captain

The captain held an airline transport pilot (ATP) certificate ratings for airplane single- and multiengine land. He also possessed a flight instructor certificate with ratings for airplane single- and multiengine instrument airplane. The captain was type rated in the ATR 72 and SD-3. At the time of this incident the captain had approximately 5,200 hours total flight time with about 1,200 hours in ATR 72/ATR 42 airplanes.

The captain was interviewed on July 10, 1995. He stated this was his first flight in N440AM on this day. He continued to state that the preparation for the flight was normal. He stated that the #2 flight attendant seat was deferred on the Master Minimum Equipment List (MMEL) so the #2 flight attendant was going to be sitting in seat 1B.

The captain stated that he had no indication that there were any problems with the main cabin entry door prior to takeoff. He stated that taxi and takeoff were normal until reaching an altitude of about 600 feet agl. It was at this time, according to the captain, that they received a "master caution single chime" and a "door unlocked" warning. Simultaneous with these warnings a pressurization loss occurred and vibrations were felt. He stated they leveled the airplane and slowed the airspeed to 130 knots indicated airspeed. He stated the #2 flight attendant called and stated there was a problem in the back of the airplane. He instructed her to stay away from the rear cabin door as it was unlocked. He then informed the first officer that they needed to return immediately to the airport. The first officer coordinated the return to the airport with air traffic control.

The captain stated they used 15 degrees of flaps for takeoff and had lowered the flaps to 30 degrees for the landing. He stated the climb sequence was complete with the gear retracted when they received the master caution indication. He stated there were noticeable yet controllable yaw oscillations when the door opened and he felt the door did not separate from the airplane until short final approach when the oscillations seemed to dissipate.

The captain stated that the cockpit crews rely on the cockpit annunciator lights to let them know when the doors are closed.

First Officer

The first officer held an ATP certificate with ratings for airplane single- and multiengine land. He also possessed a flight instructor certificate with ratings and limitations for airplane single- and multiengine instrument airplane. In addition, the first officer held a ground instructor rating. At the time of the incident the first officer had approximately 2,650 hours total flight time with about 900 hours in the ATR 72/ATR 42 airplanes.

The first officer agreed with the events as related by the captain but reiterated that he remembered hearing the captain telling the flight attendant to "stay away from the door." He stated that upon landing he went to the back of the airplane and saw the #1 flight attendant in the mid-cabin area. He stated that passengers had wrapped her arm in magazines secured with rubber bands. He then escorted the injured flight attendant off of the airplane.

The first officer stated that this was to be their last leg of the day. He stated that this same cockpit and cabin crew had flown together from O'Hare to Indianapolis and back to O'Hare on the day of the incident.

#1 Flight Attendant

The #1 flight attendant was first interviewed in the early morning hours following the incident as she was preparing to leave the hospital after having been treated for injuries sustained during the incident. She stated that she had just flown in from Indianapolis and this was to be her last leg of the day. She was acting as the "lead" or #1 flight attendant in the rear of the airplane during the incident flight and that the #2 flight attendant was sitting in seat 1B because the forward jumpseat was broken.

She stated she closed the main passenger entry door and looked to assure that both "eyelets" were showing green indicating that the door was locked. She stated they would show pink/red and white stripe if the door was not locked. She stated she then sat in her jumpseat and strapped herself in using both the seatbelt and shoulder harness. She stated she heard a loud "humming" noise coming from the door after takeoff. She stated the noise got progressively louder until the door came open.

She stated that once the door came open, her reaction was to get away from the open door. She stated she started yelling "help me, help me" as she unfastened her restraints and dove forward into the aisle. Several passengers helped pull her into the cabin area and held onto her for the remainder of the flight.

She stated she sustained her injuries when she dove onto the floor.

According to the #1 flight attendant, she did not use the interphone to contact either the #2 flight attendant or the cockpit crew regarding the noise from the door. When asked to describe the procedure for closing the door, the #1 flight attendant twice stated that you pull the door up, disconnect the pin and pull down on the handle to lock the door. After an Association of Flight Attendants union representative reminded her that this airplane had the new modified door, she corrected herself and said you "pull the handle up" to lock the door.

The #1 flight attendant stated she graduated from training on June 6, 1995, and she spent most of her time flying in the ATR-72. She once again reiterated that she was strapped into her jumpseat when the door came open.

The #1 flight attendant was interviewed again later in the afternoon on the day following the incident. Once again she stated she did not see anything wrong with the door prior to takeoff and that the noise she heard was very loud and unlike anything she has ever heard in the past. She stated that the handle was in the up position and the green eyelets were showing during the time she was hearing the noise. She reported hearing a loud "pop" and being "jerked toward the door" when the door opened up. She stated she did not know at what point the door actually separated from the airplane.

She stated that the simulator she was trained on had the modified door handle and that there were no emergency procedures for this type of emergency. (The American Eagle Inflight Manual, Section 60-1, page 11, addresses procedures for Unusual Air Leaks.)

This flight attendant had been on pager reserve. She stated that on the day prior to the incident she was called around 1300 for 1500 duty time. She stated she flew three legs that day and spent the night in Milwaukee, arriving at the hotel after 2200. On the day of the incident she received a 0500 wake-up call and reported for duty at the airport at 0630. She estimated she had approximately 5 hours of sleep. On the day of the incident she flew as the #2 flight attendant from Milwaukee to Chicago; Chicago to Grand Rapids; Grand Rapids to Chicago; Chicago to Ft. Wayne; and Ft. Wayne back to Chicago, arriving at 1630. Upon arriving back in Chi...