# NTSB DCA21LA024: Bombardier CL600 2C10, N778SK, Phoenix, AZ, November 14, 2020 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: November 13, 2020, 17:50 local (Nov 14, 2020, 00:50 UTC) - Place: Phoenix, AZ - Coordinates: 33.4373, -112.0078 - Nearby events: https://openairdocs.org/map.md?lat=33.4373&lon=-112.0078&mi=10 - Phase of flight: [Other](https://openairdocs.org/ntsb-phases/800) (OpenAirDocs' grouping) - Defining event: [Other: Cabin safety event](https://openairdocs.org/ntsb-events/110) - Highest injury: Serious injuries - Injuries: 1 serious, 60 uninjured - 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 - NTSB case key (mKey): 102304 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA21LA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102304/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102304 - Page: https://openairdocs.org/ntsb/DCA21LA024 ## Probable cause The flight attendant’s use of improper procedures when opening the main cabin door. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Cabin crew (probable cause); cases with it: [Bombardier CL-600-2C11, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1390021), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Other: Cabin safety event](https://openairdocs.org/ntsb-events/110) (defining event); cases with it: [Bombardier CL-600-2C11, 1 case](https://openairdocs.org/ntsb-events/110/sequence.md?model=1390021), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md) ## 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](https://openairdocs.org/aircraft/N778SK), registered now, S/N 10242, built 2006 (OpenAirDocs) - Reported make and model: BOMBARDIER CL600 2C10 - Registry model: [Bombardier CL-600-2C11](https://openairdocs.org/model/bombardier-cl-600-2c11) (registry code 1390021) (OpenAirDocs) - Registry engine: [GE CF34-8C5B1](https://openairdocs.org/engine/ge-cf34-8c5b1) (registry code 30052, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 10242 - Year 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: none; 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 - Co-pilot; age 28; injuries: none; 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 - Cabin crew; injuries: serious; seat: front - 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 files) The files NTSB released with the investigation on July 8, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102304. 2.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12049800&FileExtension=pdf&FileName=NTSB%206120.1%20Form_Redacted-Rel.pdf - Witness statements (item 2, PDF, 4 pages, 626 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12051651&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Flight attendant interview (item 3, PDF, 3 pages, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12051661&FileExtension=pdf&FileName=FA%20Injury%20Safety%20Investigation-with%20Interview_Question_Notes-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.