Air Wisconsin Airlines Bombardier, Inc. CL-600-2B19 accident
Bombardier, Inc. CL-600-2B19 · Accident: decompression before flight
From Chicago O'Hare International Airport (ORD) to Lehigh Valley International Airport (ABE)
Event
- NTSB case
- DCA05MA071
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- API-reported fatalities
- 0 · all aircraft and ground
- Ground fatalities
- 0
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- Airline
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Visual Meteorological Cond
Bombardier, Inc. CL-600-2B19
- Aircraft type
- Bombardier CL-600
- Category
- Airplane
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N417AW
- Operator
- Air Wisconsin Airlines
- Onboard fatalities
- Unknown
- Route
- From Chicago O'Hare International Airport (ORD), Chicago O'Hare, ILTo Lehigh Valley International Airport (ABE), Allentown, PA
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 121: Air Carrier
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Prior to flight
- First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- Decompression
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Minor
Cause areas
- Pilot in command › Procedures/directives, not followed
Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.
NTSB narrative
While the flight crew was preparing the aircraft for flight, the flight attendant opened the service door and was ejected onto the tarmac and seriously injured. At the time of the accident, the airplane was being cooled by an external diesel powered air conditioning cart that pressurizes the cabin when the airplane doors are closed. The external air conditioning cart was required because the auxiliary power unit was inoperative. The captain said that he briefed the flight attendant, before boarding the airplane and again in the cockpit, to keep one door open. The captain did not specify that the reason the flight attendant needed to keep a door open was because the air conditioning cart pressurized the cabin if all the doors were closed. After passenger boarding was completed the flight attendant stated she approached the cockpit and the captain asked her to close the main cabin door and the service door. She closed the service door, and crossed the galley and closed the main cabin door. Right afterward, the captain felt the pressure rise in his ears and yelled "GET THE DOOR OPEN." The flight attendant approached the service door and bent down, held the service door assist handle with her left hand and opened the service door with her right hand. As the service door unlatched it forcefully opened and ejected the flight attendant onto the ground. Although the flight crewmembers and ramp operators receive training regarding the operation and warnings of pressurizing the cabin when the air conditioning cart is hooked up to the airplane, the flight attendants do not receive any training on the operation and warnings for the external air conditioning cart. The airplane has two placards warning to keep a door open when the air conditioning cart is hooked up to the airplane. One placard is on the overhead console in the cockpit and the other is outside of the cabin on the fuselage skin directly above the connection for the external air conditioning cart.
Probable cause
The opening of the service door when the airplane was pressurized. Contributing to the accident was the captain's failure to ensure that one of the airplane doors was open while a ground-cooling cart was connected, which resulted in pressurizing the airplane on the ground.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record DCA05MA071
- Event ID
- 20050929X01547
- Case number
- DCA05MA071
- Dataset
- historical-pre2008
- Source SHA-256
- 89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Source notes (4)
- Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
- Filled from the NTSB case API where the bulk record had no value: local date, investigation status, coordinates. Values present in the bulk record are kept.
- The date is the local date; the NTSB stores the UTC date 2005-06-01.
- API snapshot SHA-256: 1b972a0338e02aab5d74b4cc98acd82578b8730d2a7278f361be87ffa8695f40; retrieved 2026-09-18T15:02:05.582Z.