# NTSB LAX05LA083: Aircraft Mfg & Dev. CH-2000, N285AM, Jean, NV, December 17, 2004 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 17, 2004, 10:30 local (18:30 UTC) - Place: Jean, NV - Coordinates: 36.029998, -115.599441 - Nearby events: https://openairdocs.org/map.md?lat=36.0300&lon=-115.5994&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report March 28, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 60956 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX05LA083 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60956/pdf - Page: https://openairdocs.org/ntsb/LAX05LA083 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, maneuvering - door - separation (cause) - procedures/directives - not followed, unknown (cause) ## 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](https://openairdocs.org/deregistered/N285AM-2018-03-21), registration cancelled 2018-03-21, S/N 20-1046, built 2004 (OpenAirDocs) - Reported make and model: Aircraft Mfg & Dev. Co. (AMD) CH-2000 - Registry model: [Aircraft Mfg & Development CH 2000](https://openairdocs.org/model/aircraft-mfg-development-ch-2000) (registry code 0033001) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 20-1046 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 76; injuries: none; 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 - Pilot; age 39; injuries: serious; 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 (OpenAirDocs). - [Incident 20041217032359I](https://openairdocs.org/incident/20041217032359I), Dec 17, 2004: Amtr ALARUSCH2T, Jean, NV, Minor damage. (-23) Aircraft was involved in a demonstration flight to a perspective buyer when this incident occurred. Aircraft was at approximately 5,000 feet, in a 30… ## Other investigations on N285AM (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 WPR14LA153](https://openairdocs.org/ntsb/WPR14LA153), Mar 6, 2014: Zenair CH2T (N285AM), Woodland, CA, substantial damage. Probable cause: A total loss of engine power during approach due to carburetor icing, which resulted in an off-airport landing into trees. 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.