# NTSB WPR09LA075: Czech Aircraft Works Sport Cruiser, N797BS, Casa Grande, AZ, January 6, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 6, 2009, 16:00 local (23:00 UTC) - Place: Casa Grande, AZ - Coordinates: 32.954723, -111.766944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.9547&lon=-111.7669&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 15, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73204 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA075 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73204/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73204 - Page: https://openairdocs.org/ntsb/WPR09LA075 ## Probable cause The pilot's failure to ensure that the canopy was latched prior to takeoff. Contributing to the accident was the inadequate guidance in the Pilot Operating Handbook regarding canopy procedures. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause) - [Design: design of document/info](https://openairdocs.org/ntsb-findings/04011020): Organizational issues › Development · Manufacturer (probable cause) - [Selection/certification/testing](https://openairdocs.org/ntsb-findings/04012000): Organizational issues › Development · Other institution/organization - [Doors: passenger/crew doors](https://openairdocs.org/ntsb-findings/01035210): Aircraft › Aircraft structures · Incorrect use/operation (probable cause) ## Analysis The pilot followed the manufacturer’s before-takeoff checklist, but failed to ensure that the canopy was latched prior to takeoff. The canopy of the Special Light Sport category airplane popped open during the initial climb, about 500 feet above ground. The canopy is hinged in front of the cockpit and rotates upward when open. The pilot said that he tried to keep the canopy closed with his free hand but the canopy continued to rise higher and higher. The pilot turned back to the airport and made an off-field landing. Inspection of the canopy latch mechanism revealed no mechanical anomalies, and the canopy latch hooks aligned with the canopy frame latch slots. When the airplane is static, the canopy will remain in the closed position with the canopy lever in the ‘open’ (unlatched) position. By design the canopy latch lever is positioned behind the pilot’s right elbow, and not in direct view when looking forward or at the instrument panel. The manufacturer does not provide a ‘canopy unlatched’ warning device, and the Pilot Operating Handbook does not include a checklist step to check that the canopy is latched. It also it does not provide procedures for the pilot to execute if the canopy is unlatched or becomes unlatched in flight. The ASTM standard that guides Light Sport Aircraft design does not address canopy latching/locking systems or the associated Pilot Operating Handbook information. ## Factual narrative On January 6, 2009, at 1600 mountain standard time, a Czech Aircraft Works (CZAW) Sport Cruiser, N797BS, made an emergency off field landing after the cockpit canopy popped opened in flight at Casa Grande Municipal Airport, Casa Grande, Arizona. The sport pilot operated the special light sport airplane (S-LSA) under the provisions of Title 14 Code of Federal Regulations, Part 91. The pilot was not injured, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated at Casa Grande a few minutes earlier. The pilot reported to the Safety Board investigator that he performed the 'before flight' checklist before taking off. During the initial climb, about 500 feet above ground, the canopy popped open. The canopy is hinged in front of the cockpit and rotates upward when open. The pilot said he tried to keep the canopy closed with his free hand but the canopy continued to rise higher and higher. The pilot turned back to the airport and made an off field landing next to the airport windsock. The left wing struck a scrub tree, partially separating the wing from the fuselage, and broke the canopy glass. On January 12, 2009, the Safety Board investigator-in-charge examined the airplane. About 90 percent of the canopy glass had been broken out at the time of the exam. The canopy is locked down using two latches, one on each side of the cockpit, which engages the canopy frame. Both latches are engaged using a single lever that is positioned between the cockpit seats on the aft cockpit bulkhead. The lever operates a torque tube that is behind the cockpit seats and extends across the cabin; at each end of the toque tube are push-pull rods that operate the latch hooks. The latch lever is positioned behind the pilot’s right elbow, and is not in direct view when looking forward or at the instrument panel. The latch mechanism exhibited no mechanical damage or misalignment. The canopy hooks aligned with the canopy frame latch slots. The canopy frame was lowered into the closed position and repeatedly latched and unlatched; no mechanical malfunction was encountered over the course of the attempts. It was noted that on the static airplane the canopy will stay in the lowered (closed) position even if the canopy latch is not engaged. The following was noted regarding information included, and not included, in the airplane's "Pilot Operating Handbook" (POH), issued on 12/2007, as revision 2.0: 1. In step #4 of the 'before takeoff' checklist, the POH states 'Cockpit canopy – closed'. The POH does not include a step to check that the canopy is latched [or locked]. 2. The emergency procedures section of the POH does not include a procedure for the pilot to follow if the canopy becomes unlatched during flight. 3. There is no discussion in the POH about the airplane's flight characteristics with an unlatched canopy. Special Light Sport Airplanes are designed and constructed in accordancewith ASTM International standard F2245-07. Standard F2245-07 does not specify requirements for canopy security, or the use of any type of latched/unlatched indicator in the cockpit. The ASTM standard also lists the required information that should be contained in the POH. There is no guidance in the standard indicating that the manufacturer should include information in the POH about canopy security before flight and in flight. A representative of the manufacturer stated that the airplane is fully controllable if the canopy becomes unlatched in flight, and that the canopy will remain slightly open. The relative airflow over the canopy will keep it in a lowered position. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440) ## Aircraft - Registration: N797BS (not matched to a registry record) - Reported make and model: Czech Aircraft Works Sport Cruiser - Category: Airplane - Serial number: 08SC115 - Airframe hours: 105 - Engines: Rotax 912ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Robert A Switzer - Registered owner: Robert A Switzer - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: AAIP, May 22, 2008 - Departed: KCGZ, Casa Grande, AZ - Destination: KFFZ, Falcon Field, AZ - Airport: KCGZ, Casa Grande Municipal Airport, runway 05, 5,200 × 100 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: none; sport pilot; medical: sport pilot; last flight review November 2, 2008; seat: left; flight hours: 58 total, 31 in this make and model, 16 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 25 °F - Altimeter: 30.10 inHg - Observed at: KCGZ ## 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 20090106000319A](https://openairdocs.org/incident/20090106000319A), Jan 6, 2009: Czawsp SPORTCRUISER, Casa Grande, AZ, Substantial damage. On jan. 06, 2009 at 1645 MST the student pilot took off from cgz runway 05 under clear skies. At approx. 500 AGL the pilot reported that the canopy popped open… ## Docket (14 files) The files NTSB released with the investigation on September 25, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73204. 5.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 606 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317860&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317854&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Photo 1 - Left side of airplane (item 3, .PDF, 616 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317855&FileExtension=.PDF&FileName=Photo%201%20-%20Left%20side%20of%20airplane-Master.PDF - Photo 2 - Aft view of airplane (item 4, .PDF, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317856&FileExtension=.PDF&FileName=Photo%202%20-%20Aft%20view%20of%20airplane-Master.PDF - Photo 3 - Canopy latch lever (item 5, .PDF, 595 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317857&FileExtension=.PDF&FileName=Photo%203%20-%20Canopy%20latch%20lever-Master.PDF - Photo 4 - Latch Mechanism (Left side) (item 6, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317992&FileExtension=.PDF&FileName=Photo%204%20-%20Latch%20Mechanism%20(Left%20side)-Master.PDF - Photo 5 - Latch Hook Exterior (Left Side) (item 7, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317993&FileExtension=.PDF&FileName=Photo%205%20-%20Latch%20Hook%20Exterior%20(Left%20Side)-Master.PDF - Photo 6 - Left side latch hook (item 8, .PDF, 854 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318958&FileExtension=.PDF&FileName=Photo%206%20-%20Left%20side%20latch%20hook-Master.PDF - Photo 7- Left side latch pushrod (item 9, .PDF, 684 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318959&FileExtension=.PDF&FileName=Photo%207-%20Left%20side%20latch%20pushrod-Master.PDF - Photo 8- Right side latch hook (item 10, .PDF, 821 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318960&FileExtension=.PDF&FileName=Photo%208-%20Right%20side%20latch%20hook-Master.PDF - Photo 9- Right side latch pushrod (item 11, .PDF, 664 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318961&FileExtension=.PDF&FileName=Photo%209-%20Right%20side%20latch%20pushrod-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319286&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Wreckage Exam Field Notes (item 13, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317859&FileExtension=.PDF&FileName=Wreckage%20Exam%20Field%20Notes-Master.PDF - Sport Cruiser Before Flight Checklist (Extract) (item 14, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318962&FileExtension=.PDF&FileName=Sport%20Cruiser%20Before%20Flight%20Checklist%20(Extract)-Master.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.