What happened
On April 3, 2002, a Fokker 100, registration PT-MQP, operated by TAM Transportes Aéreos Regionais, was performing a scheduled passenger flight from Rio de Janeiro (SBGL) to Porto Alegre (SBPA). The aircraft was carrying 43 passengers and 6 crew members.
During the takeoff roll on runway 10, the nose gear made contact with runway centerline lights, producing a series of rhythmic noises and vibrations. A flight attendant trainee, who was undergoing training for the purser position, misinterpreted these vibrations as a sign that the main passenger door was unlocked. Believing the door was insecure, the trainee unbuckled their seatbelt, stood up, and cycled the door handle. This action released the door locks, allowing the aerodynamic forces of the takeoff to push the door open to its full extent at approximately 4/00 feet AGL.
The cockpit alarms immediately alerted the pilots to the door's status. The crew notified air traffic control of a technical issue and requested an immediate return to Rio de Janeiro. During the subsequent landing on runway 15, the open door made contact with the ground, resulting in significant damage to the door's lower section, the lever, and the actuator plate. Despite the incident, all 49 occupants remained uninjured.
The investigation
CENIPA's investigation focused on the sequence of events leading to the door opening and the adequacy of crew training. Investigators examined the aircraft's maintenance records, flight data recorder (FDR) and cockpit voice recorder (CVR) information, and the training protocols of the operator.
Technical inspections of the aircraft's door locking and warning systems, conducted in coordination with the manufacturer, Fokker, confirmed that all mechanical and electrical components were functioning correctly and that the warning systems were operational. The investigation also reviewed the training environment, noting that the airline lacked a dedicated mock-up for cabin crew training, often relying on visits to aircraft during maintenance periods.
Findings
- Inadequate training: The flight attendant trainee had not been sufficiently trained to distinguish between mechanical vibrations from the runway and the actual status of the door locking mechanism. Furthermore, the instructor did not supervise the door closure process during this specific flight.
- Deficient supervision: The airline's training program lacked adequate simulation equipment, such as a mock-up, which limited the crew's ability to practice emergency procedures and abnormal situations.
- Poor crew coordination: There was a lack of effective communication between the trainee and the instructor during the event. Additionally, the instructor's insistent use of the interphone to notify the cockpit created a distraction that interfered with sterile cockpit procedures.
- Failure to declare emergency: The pilot did not formally declare an emergency to air traffic control, despite the critical nature of the situation.