LAX05LA083

NTSB accident investigation · Aircraft Mfg & Dev. CH-2000 · Jean, NV · December 17, 2004

Accident · Serious injuriesLimited investigationFinal report
Date
December 17, 2004, 10:30 local (18:30 UTC)
Place
Jean, NV
Injuries
1 serious, 1 uninjured
Damage
Minor damage
Phase of flight
Maneuvering
Aircraft
N285AMAircraft Mfg & Dev. CH-2000
Weather
Visual (VMC) · Day
Status
Completed · report March 28, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20041217032359I
Case key
60956

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

an in-flight separation of the left cockpit door due to the failure of the hinges from repeated exposure to wind or propeller slip stream forces while in the open position. The hinge failures were the ultimate result of the failure of persons unknown to follow the procedures/directives in the airplane flight manual.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionManeuvering
Door - separationCause
Procedures/directives - not followedUnknownCause

Analysis

The airplane's clamshell canopy door departed the airframe and struck the pilot's shoulder, while in a banking maneuver. As the pilot initiated a 30-degree turn to the left, the airplane's left canopy door suddenly became ajar, and he experienced difficulty flying the airplane. He attempted to regain control of the airplane, and about 2 to 3 seconds later, the door canopy separated completely from the airframe. After detaching, it struck the pilot's left shoulder, and then impacted the side of the fuselage; he landed at the airport without further incident. After egressing the cockpit, both pilots noted that the canopy latching mechanism was still in the locked position, affixed to the airframe. After several doctor's visits, the pilot was determined to have suffered tendon damage to his left shoulder. Technical examination of the airplane disclosed that the upper aft hinge of the canopy door failed first, followed by the forward hinge and a bolt attaching the bottom latch to the frame. The hinge had apparently undergone stress from the door remaining open during windy conditions or while the propeller was under power over an undetermined number of prior flights. The airplane's flight manual indicates in several locations that the door is to remain closed during such conditions.

Factual narrative

On December 17, 2004, about 1030 Pacific standard time, an Aircraft Manufacturer and Development Co. Alarus CH-2000, N285AM, was damaged when the door departed the airframe and struck the pilot's shoulder, while maneuvering near Jean, Nevada. American Aviation was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) was not injured and the private pilot sustained serious injuries; the airplane sustained minor damage. Visual meteorological conditions prevailed, and a flight plan had not been filed. The local check-out flight originated from Jean Airport about 1000.

In a written statement, the private pilot reported that after departing the airport, he maneuvered the airplane into a climb until reaching 5,000 feet mean sea level (msl), where he configured the airplane in a level attitude. With the intention of performing a series of maneuvers for practice flight, he initiated a 30-degree turn to the left. While in the bank, the airplane's left canopy door suddenly became ajar, and he experienced difficulty flying the airplane. He attempted to regain control of the airplane, and about 2 to 3 seconds later, the door canopy separated completely from the airframe. After detaching, it struck the pilot's left shoulder, and then impacted the side of the fuselage.

The pilot further stated that the separation of the left canopy door resulted in a rapid loss of airspeed and his ability to maintain control of the airplane, requiring an emergency decent and landing. He landed the airplane at Jean without further incident. After egressing the cockpit, both pilots noted that the canopy latching mechanism was still in the locked position, affixed to the airframe. After several doctor's visits, the pilot was determined to have suffered tendon damage to his left shoulder.

A Federal Aviation Administration (FAA) inspector examined the airplane and interviewed the pilots after the accident occurred. He reported that the private pilot was undergoing a demonstration flight with the CFI, and remained pilot-in-command of the airplane throughout the flight. With the airplane cruising about 75 knots indicated airspeed, the pilot initiated a 30-degree bank, and upon entering the turn, the left canopy door separated from the airframe. While departing the airplane, the door struck the private pilot's left shoulder, ripped the nylon retaining strap from the composite fiber cockpit frame, and proceeded to slide along the left side of the fuselage, scratching the surface; no damage was found to the flight control surfaces. The canopy's lock/latch mechanism remained latched down in the "closed" position within the doorframe; the door was not located.

During a telephone conversation with a National Transporation Safety Board investigator, a representative from Aircraft Manufacturer & Development Co. stated that after examining the hinges and pictures of the doorframe, they determined that the upper aft hinge of the canopy door failed first, followed by the forward hinge and a bolt attaching the bottom latch to the frame. The representative reported that the hinge had apparently undergone stress from the door remaining open during windy conditions or while the propeller was under power. The airplane's flight manual indicates in several locations that the door is to remained closed during such conditions. The representative added that the airplane is controllable with a door absent.

The airplane is designed with both a left and right side door, both of which open upward, akin to a clamshell configuration. The canopy door is attached to the airframe via two congruent hinges oriented on the top of the airplane, and parallel the longitudinal axis. The pilot secures the door in the closed position via a handle, which manipulates the latch, locking the door to the doorframe.

Aircraft

Registration
N285AM
Reported as
Aircraft Mfg & Dev. CH-2000
Category
Airplane
Serial number
20-1046
Engine
Lycoming O-235, 116 horsepower, reciprocating
Damage
Minor damage
Flight
Instructional · Part 91
Operator
American Aviation
Registered owner
Nimbus II LLC
Airworthiness certificate
Standard, Normal
Departed
0L7 · Jean, NV
Airport
0L7 · Jean 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
76
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
August 1, 2004
Seat
Right
Flight hours
22,475 total · 3 in this make and model · 21,500 as pilot in command · 10 in the last 90 days · 5 in the last 30 days
Role
Pilot
Age
39
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
July 1, 2004
Seat
Left
Flight hours
176 total · 1 in this make and model · 141 as pilot in command · 63 in the last 90 days · 47 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 21 °F
Altimeter
30.50 inHg
Observed at
LAS, 21 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.

Other investigations on N285AM · 1

Matched to the same aircraft by N-number and date.