UVA-Pegasus Medical Transport Network - Non-injury incident

Date: 3-16-2008 0622 EDT

Program: UVA-Pegasus Medical Transport Network
	University of Virginia Medical Center
	PO Box 801471
	Charlottesville, VA 22908-1471

Type: Agusta 109E
Tail #: N5UV
Operator/Vendor: OmniFlight

Weather: Clear. Not a factor

Team: Pilot, Flight Nurse, Flight Paramedic. No injuries reported. Patient on board. 

Description: 
	N5UV the program?s Agusta109E had recently undergone routine
	maintenance.  There had been several maintenance flights prior to
	placing the aircraft back in service.  The aircraft was placed back in
	service in time for night shift on 03/15/2008.  At 06:22 aircraft
	responded to inter-facility flight.  Outbound leg of the flight was
	unremarkable.  On return flight to University of Virginia Medical
	Center, pilot noticed door light illuminated during cruise speed. 
	Seconds after door light illumination, the right cabin door opened
	abruptly and violently.  One crew member that was out of their
	seatbelt attending to patient, rapidly returned to belted position and
	verified security of all equipment.  Attempts made to close the door
	by medical crew members during near cruise speed were unsuccessful.
	Pilot slowed to 30 knots and door was closed and secured by medical
	crew members.   Door was closed and locked, cockpit door warning light
	went off.   Flight concluded without further incident.  
	
	Prior to returning to the airport the door mechanism was inspected by
	the pilot and the door was tested and appeared to function
	appropriately and was secure.  Prior to any further flight activities
	the crew discussed whether or not the procedure of closing and locking
	the door and the potential deviations in the process of double
	checking security of the doors could have been contributory in the in
	security of the door during this incident.  Immediate attention was
	given to this issue and the crew took measures to elevate situational
	awareness associated with door procedure and checklist completion.  
	
	The aircraft returned to airport without door warning lights or door
	issues.  Maintenance was advised and performed an inspection of the
	mechanism which appeared to functioning without difficulty.  A loose
	roller was discovered and replaced although it was not felt that this
	could be a major contributing factor to the door opening event.  The
	maintenance staff continued to investigate the problem by examining
	the internal door mechanism in detail. It was discovered that the
	interconnection link had unexpected signs of wear.  There was noted
	wear to the pin which possibly could have contributed to the door
	incident.  The interconnection link was replaced with new parts. The
	aircraft maintenance staff conducted some additional research into the
	matter and reviewed a 2003 service bulletin from Agusta regarding door
	opening that recommended changing the interconnection link.  At the
	time this bulletin was published both cabin doors (on N5UV) had their
	interconnection links changed.
	
	Since this incident no other issues have been noted with the door. 
	The program has approached the issue with a multi-dimensional
	intervention.  Maintenance staff will routinely inspect internal door
	handle and locking mechanisms, greater diligence and attention to
	process detail will be devoted to preflight crew checklist for door
	handle and equipment security, and the situation has been formally
	reviewed by the safety committee and information has been disseminated
	to all staff members.   Agusta Westland has been advised of this issue
	and has been very supportive in further examination of the door
	components.  Worn components have been sent to Agusta who has kept an
	open dialogue with the program?s maintenance staff.  Any follow-up
	information conveyed from Agusta will be disseminated to all staff
	members.
	

Source: Scott Kunkel - Program Director

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programs when an accident / incident has occurred. Please share the above
information with your program staff. If you have further questions, please
contact the CONCERN Coordinator, David Kearns at 800 525 3712 or email:
coordinator@concern-network.org.

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