# NTSB DEN03IA101: Boeing 757-200, N704X, Dodge City, KS, June 10, 2003 - Type: NTSB incident investigation - Classification: Incident · Minor injuries · Incident investigation · Final report - Date: June 10, 2003, 10:30 local (16:30 UTC) - Place: Dodge City, KS - Coordinates: 37.750396, -100.009208 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.7504&lon=-100.0092&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 173 uninjured - Status: Completed, report September 1, 2004 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 57192 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN03IA101 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57192/pdf - Page: https://openairdocs.org/ntsb/DEN03IA101 ## Probable cause the inadvertent activation of the flight deck door's upper pressure relief latch during closure of the door, resulting in the deployment of the upper decompression panel which subsequently struck the captain. Contributing factors included the operator's improper compliance with the door manufacturer's service bulletin, the operator's inadequate service and maintenance of the flight deck door, and the door manufacturer's inadequate service bulletin compliance determination. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, cruise - door,interior crew - deployed inadvertently (cause) - door,interior crew - disengaged (cause) - maintenance,service bulletin/letter - not complied with, company/operator management (contributing factor) - maintenance - improper, company/operator management (contributing factor) - inadequate certification/approval, faa(organization) - acft/equip,inadequate compliance determination, manufacturer (contributing factor) - Miscellaneous/other, emergency descent/landing - emergency procedure - performed, pilot in command ## Analysis The lead flight attendant had given the captain a tray of refreshments and was attempting to secure the flight deck door. When the flight attendant slammed the door closed, the upper pressure relief latch activated, causing the upper decompression panel to open. The panel fell forward and down, striking the captain on the head. The captain received a 1-inch cut on his head. The first officer requested and received clearance for an immediate descent and landing at Denver, Colorado. An examination of the flight deck door showed the correct placard in place; however, the door was not in compliance with the manufacturer's issued Service Bulletin (SB), B231001-52-02 for the Boeing model 757-200 flight deck door. On further examination, the doorstop mechanism, mounted on the bottom of the flight deck door, was found to be loose and missing one attachment screw. According to an FAA inspector, this misalignment would cause the door to "hang and catch" the floor, requiring added force to close the door. The SB instructed that modified pressure relief latches and latch spacers be installed on the upper and lower decompression panels on flight deck doors, and latch straps be installed on upper panels. The airline company and the Federal Aviation Administration (FAA) were aware of previous problems with the flight deck door latches. The NTSB issued an urgent safety recommendation letter requesting the FAA issue an Airworthiness Directive that required compliance with the SB within 90 days. The FAA subsequently issued the appropriate AD. ## Factual narrative HISTORY OF FLIGHT On June 10, 2003, at 1030 mountain daylight time, a Boeing 757-200, N704X, owned by ILFC VOLARE Inc., and operated by Trans World Airlines (TWA) LLC, as American Airlines flight 2885, was in cruise flight at 35,000 feet, 34 nautical miles southwest of Dodge City, Kansas, when the captain was struck on the head by the flight deck door's upper decompression panel, rendering him incapacitated. The first officer requested an immediate flight deviation to Denver, Colorado, where he made an uneventful landing. The airline transport certificated captain received minor injuries. The airline transport certificated first officer, 3 flight attendants, and 93 passengers were not injured. Visual meteorological conditions prevailed at the time of the incident. The scheduled domestic passenger flight was being conducted on an instrument flight rules (IFR) flight plan under the provisions of Title 14 CFR Part 121. The flight originated at St Louis, Missouri, at 0955 central daylight time, and was en route to Santa Ana, California. According to witnesses aboard the plane, the lead flight attendant had given the captain a tray of refreshments and was attempting to secure the flight deck door. While slamming the door, the upper pressure relief latch activated, and the upper decompression panel opened, falling forward and down, striking the captain on the head. The captain received a 1-inch cut on his head. The first officer requested and received clearance for an immediate descent and landing at Denver, Colorado. A "deadheading" captain, who was seated in the cabin, assisted the injured captain and then assisted the first officer as the first officer made an uneventful landing at Denver International Airport at 1055 mountain daylight time. When the airplane arrived at the gate, the injured captain was taken to the hospital. A replacement flight crew took control of the airplane and began departure preparations to continue the flight to Santa Ana, California. At that same time, maintenance personnel boarded the airplane to assess the security of, and perform an operational check of the flight deck door. A maintenance technician, whom was called to check N704X's flight deck door, stated that he was given a report indicating that the lead flight attendant had closed the flight deck door "excessively hard," which caused the upper flight deck door decompression panel to deploy. He said he inspected the flight deck door, reinstalled the upper decompression panel, and completed an operational check of the flight deck door from inside the cockpit. The maintenance technician closed the flight deck door several times with "a good amount of force," and said that "the panel held without releasing." The lead flight attendant then assisted the maintenance technician as they closed the flight deck door together. The maintenance technician said that he remained in the cockpit as the lead flight attendant closed the flight deck door. He said that when the lead flight attendant demonstrated how she closed the door in-flight, she "slammed the door shut with a great amount of force." The slamming of the door caused the "fuse mechanism to release" and the upper decompression panel to fall forward and down into the technician's hands. The maintenance technician stated that he contacted TWA maintenance with the information and was told, "It was normal." He was then told to reinstall the panel. He reinstalled the upper decompression panel and signed off the write-up as: "Reinstalled upper panel in flight deck door, door operation checks good. Maintenance Manual Reference: 52-51-00-0, item 2C and 2D." Following the completion of the maintenance checks, the replacement flight crew requested and received clearance for pushback and taxi. The crew taxied the airplane out for departure to Santa Ana. When the airplane arrived in Santa Ana, California, an FAA inspector from the Long Beach, California, Flight Standards District Office (FSDO), met the crew and requested to inspect, remove, and secure the airplane's flight deck door, flight data recorder (FDR), and cockpit voice recorder (CVR). Prior to removal of the flight deck door, the FAA inspector, assisted by TWA maintenance personnel, conducted several operational checks of the door. Each time the door was "slammed closed," the upper decompression panel inadvertently deployed. TWA replaced and secured the flight deck door and the recorders, and put the airplane back into revenue service. TESTS AND RESEARCH On June 11, 2003, the FDR and CVR were sent to the National Transportation Safety Board (NTSB) vehicle recorder laboratory in Washington D.C., for examination. All data contained on the FDR and CVR was downloaded. The examination showed that all CVR data relevant to the incident had been recorded over because the CVR continued to capture data as the flight proceeded from Denver to Santa Ana. Data recorded on the FDR was unremarkable. The incident flight deck door was manufactured by C&D Aerospace. An examination of the door showed that it had the correct placard mounted. However, the door did not comply with the manufacturer's issued Service Bulletin (SB), B231001-52-02 for Boeing model 757-200 flight deck door, dated December 6, 2002. On further examination, it was revealed that the doorstop, mounted on the bottom of the flight deck door, was loose and missing one attachment screw. According to FAA, this misalignment caused the door to "hang and catch" the floor, which required added force to close the door. The model number 757-200 flight deck door is similar to the model 757-300, and 737-200 through 737-900 series flight deck doors. These doors are also manufactured by C&D Aerospace. These designs include two decompression panels. The top decompression panel assembly is hinged at the bottom and is secured by a pressure relief latch at the top. The pressure relief latch is designed so that if an excessive pressure differential exists, the relief latch activates, and the decompression panel is released to fall forward, and down, into the cockpit, equalizing pressure between the flight deck and the cabin. On June 12, 2003, NTSB investigators and FAA inspectors conducted a series of flight deck door inspections and functional tests on airplanes at the Denver International Airport. The door inspections and functional tests were done on several different Boeing 757 and Boeing 737 airplanes, one of which was N704X, which had returned to Denver. Three of the airplanes checked, including N704X, had flight deck doors installed that were not in compliance with the SB. When the doors, including the replacement door on N704X, were "slammed" shut, the top decompression panel inadvertently deployed. Although each of these doors had the correct placard installed, two were incorrectly modified, and one was not modified at all. Further investigation showed that C&D Aerospace was aware of several incidents where flight deck door decompression panels had opened inadvertently. On December 6, 2002, C&D Aerospace had issued SB B231001-52-02 for Boeing model 757 and SB B221001-52-03 for Boeing model 737 doors. These SB's required installation of a new decompression latch strap (P/N B221080-1), a new pressure latch spacer (P/N B221081-1), and new hardware on the pressure relief latch. The modifications outlined in the SB were to prevent the decompression panel from opening inadvertently. Although these modifications were mandatory as outlined in an SB, according to the FAA, they were required to be completed only "as soon as manpower, facilities, and retrofit kits become available." The SB included procedures for modifying the upper and lower pressure relief latch assemblies for the reinforced flight deck door. The procedures for modifying the upper pressure relief latch assembly included removing the upper pressure relief latch assembly and spacer, ## Aircraft - Registration: [N704X](https://openairdocs.org/deregistered/N704X-2026-05-03), registration cancelled 2026-05-03, S/N 28163, built 1997 (OpenAirDocs) - Reported make and model: Boeing 757-200 - Registry model: [Boeing 757-2Q8](https://openairdocs.org/model/boeing-757-2q8) (registry code 1384972) (OpenAirDocs) - Registry engine: [Pratt & Whitney PW2037](https://openairdocs.org/engine/pratt-whitney-pw2037) (registry code 52117, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 28163 - Airframe hours: 22891 - Engines: Pratt & Whitney PW-2037 37000 lbs thrust turbo fan; Pratt & Whitney PW-2037 37000 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Operator: TWA Airlines LLC., doing business as American Airlines Flight 2885 - Registered owner: Ilfc Volare Inc. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, June 6, 2003, 26 hours before - Departed: STL, St Louis, MO - Destination: SNA, Santa Ana, CA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: minor; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 18,464 total, 3,969 in this make and model, 3,524 as pilot in command, 213 in the last 90 days, 70 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 57 °F - Altimeter: 29.86 inHg - Observed at: DDC, 34 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20030610017939A](https://openairdocs.org/incident/20030610017939A), Jun 10, 2003: Boeing 7572Q8, Denver, CO. (-23) American flight #2885, st. louis to santa ana, California (sna) diverted to Denver. While at cruise altitude the captain was struck in the forehead/nose… ## Other investigations on N704X (1) 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. - [NTSB ENG11IA016](https://openairdocs.org/ntsb/ENG11IA016), Feb 9, 2011: Boeing 757-2Q8 (N704X), Minneapolis, MN, incident, minor damage. Probable cause: the failure of the right engine's fuel control unit to operate correctly when the fuel metering valve became frozen in the full open position because of corrosion on the fuel metering valve slide and… 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.