DCA21LA024

NTSB accident investigation · Bombardier CL600 2C10 · Phoenix, AZ · November 14, 2020

Accident · Serious injuriesClass 4 · LimitedFinal report
Date
November 13, 2020, 17:50 local (Nov 14, 2020, 00:50 UTC)
Place
Phoenix, AZ
Injuries
1 serious, 60 uninjured
Damage
No damage
Phase of flight
Other
Aircraft
N778SKBombardier CL600 2C10
Defining event
Other: Cabin safety event
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Major Investigations Division
Parties
SkyWest Airlines
Case key
102304

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight attendant’s use of improper procedures when opening the main cabin door.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · Cabin crewBombardier CL-600-2C11: 1 caseAll aircraft: 1,386 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

On November 13, 2020, at about 5:50 PM Mountain standard time, a flight attendant suffered a serious injury on SkyWest flight 3145, a Bombardier CL600, N778SK, while at the gate at the Phoenix Sky Harbor International Airport (PHX), Phoenix, Arizona. Of the 61 passengers and crew onboard, one flight attendant was seriously injured, and the airplane was not damaged. The regularly scheduled passenger flight was operating under 14 CFR Part 121 from Albuquerque International Sunport Airport, Albuquerque (ABQ), New Mexico to PHX. The takeoff, cruise and landing were uneventful. After landing, the airplane taxied to the gate and came to a stop at the gate. The forward flight attendant (FA) fell from the top of the main cabin doorsteps to the ramp surface while opening the main cabin door (MCD). Phoenix ramp personnel immediately came to the FA’s aid; she was conscious and lying on her left side with multiple lacerations to the head. Airport emergency medical services arrived on scene and transported her to a local hospital where she was diagnosed with fractures to both elbows and wrists. The MCD is located on the left side of the forward fuselage and is equipped with air stairs that open outward and downward. Handrails are attached to the stairs and, if the handrail latch pins are engaged, the handrails will automatically extend to their up and locked position when the door is opened. The CRJ 700 Inflight Operations manual provides instructions for the closing and opening of the main cabin door. The manual states that the handrails must be in their up and locked position prior to closing the door. According to the operator, the FA had received and completed initial training on the CRJ 700 in September 2019 and recurrent training in September 2020. Post-accident examination of the MCD and its handrail assembly by SkyWest maintenance personnel found that the handrail was not in its up and locked position and that none of the four handrail latch pins were engaged (locked). Maintenance personnel also functionally tested the door by opening and closing it with the latch pins engaged and did not find any defects with the door or handrail; the handrail moved to its up and locked position when the door was opened. The FA indicated that she was aware of how to operate the MCD but that she was distracted by a passenger when opening the door, which may have been why she guided the MCD down with her hands resulting in her being pulled from the top of the main cabin doorsteps.

Aircraft

Registration
N778SK
Reported as
Bombardier CL600 2C10
Category
Airplane
Serial number
10242
Built
2006
Damage
No damage
Flight
Part 121
Operator
Skywest Airlines Inc
Registered owner
Skywest Airlines Inc
Airworthiness certificate
Standard, Transport
Departed
ABQ · Albuquerque, AZ
Destination
Same as departure
Airport
PHX · Phoenix Sky Harbor International Airport

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 4

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
51
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Left
Flight hours
11,516 total · 2,461.3 in this make and model
Role
Co-pilot
Age
28
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Seat
Right
Flight hours
2,216.5 total · 17.03 in this make and model
Role
Cabin crew
Injuries
Serious
Seat
Front
Role
Cabin crew
Injuries
None
Seat
Rear

Weather

Conditions
Visual (VMC) · Dusk
Wind
300° at 7 knots
Visibility
10 statute miles
Temperature
73 °F, dew point 25 °F
Altimeter
29.98 inHg
Observed at
KPHX, 1 nm away
METAR
KPHX 140051Z 30007KT 10SM FEW250 23/M04 A2998 RMK AO2 SLP142 T02281044

Docket · 3

The files NTSB released with the investigation on July 8, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.9 MB in all.