WPR21LA142

NTSB accident investigation · Davis Dan B Lancair Evolution · Phoenix, AZ · March 18, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 18, 2021, 14:27 local (21:27 UTC)
Place
Phoenix, AZ
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N469KSDavis Dan B Lancair Evolution
Defining event
Enroute-climb to cruise: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Lancair Evolution, AvSafe
FAA report
20210318018439A
Case key
102803

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

A malfunction of the main cabin door latching mechanism for reasons that could not be determined based on the available information.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Doors: passenger/crew doorsAircraft › Aircraft structures · MalfunctionDavis Dan B LANCAIR EVOLUTION: 1 caseAll aircraft: 86 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedDavis Dan B LANCAIR EVOLUTION: 1 caseAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that, while climbing through 22,000 ft mean sea level on a cross-country flight, the main cabin door departed the airplane. The pilot immediately diverted and landed uneventfully at a nearby airport. The door was not recovered. The horizontal and vertical stabilizers sustained substantial damage due to impact from the door as it departed the airplane. The kit manufacturer reported two previous door failures that had prompted the issuance of an inspection advisory to inspect the door for cracks. This inspection was not performed on the accident airplane; however, postaccident examination revealed no damage to the hinges and door latch anchors, all of which were still connected at the frame. Because the door was not recovered and could not be examined, the reason for its separation could not be determined based on the available information.

Factual narrative

On March 18, 2021, about 1427 mountain standard time, an experimental, amateur-built Lancair Evolution, N469KS, was substantially damaged when it was involved in an accident near Phoenix, Arizona. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he began a climb after he departed on an instrument flight rules flight plan from Falcon Field Airport (FFZ), Mesa, Arizona. As the airplane climbed through 22,000 ft mean sea level, about 30 nm west of the departure airport, the cabin door departed the airplane and impacted both the horizontal and vertical stabilizers. The pilot diverted and landed uneventfully. Photos of the airplane taken by the accident pilot showed substantial damage to the left horizontal stabilizer. The cabin door was not recovered. The airplane was equipped with one 42-lb main cabin door located on the left side of the cockpit that opened and closed by two hinges at the top of the door frame. When closed, the door locked the pressurized cabin through eight latches: three at the lower frame, two on the front door post, and three on the rear door post. Each latch mechanism comprised a steel latch arm and ball attached to an aluminum latch body, which was bolted to the door. The door was closed and locked when each latch arm and ball aligned and connected with its respective socket at the steel latch anchor, which is connected to the door frame. The locking mechanism was operated by a single handle rotated clockwise to lock the door, which latched the anchors through a series of sprockets and chains. Moving the handle in the opposite direction would unlatch the latches. (see figure 1) Figure 1: Lancair Evolution Door Latch and Anchor Alignment According to the kit manufacturer, two potential main door failures had been reported to the company. The first failure occurred in 2010 on another airplane that resulted when a latch was not aligned over center and failed to secure to the latch body. This forced the adjacent latch mechanisms to carry the load, which caused one of the adjacent latches to fail at the aluminum latch body. Another failure occurred in November 2020 and resulted in an explosive decompression during cruise flight as the lower rear latches were not secured. According to the manufacturer, the cause was likely attributed to a failure of the lower rear latch to secure before takeoff. Once the load overstressed the forward latches, they failed in a domino effect that resulted in an explosive decompression. This prompted the manufacturer to issue an inspection advisory that required an inspection of the main door latches for cracks or other physical damage within the next 10 hours of flight. The advisory was issued to all maintenance facilities that regularly serviced their airplanes about three months before the accident airplane received its most recent service. The airplane’s maintenance logbooks did not indicate that theairplane had been inspected in accordance with the advisory and the maintenance facility that regularly serviced the airplane reported that they were not aware of the advisory. An examination of the accident airplane fuselage frame by a Federal Aviation Administration inspector revealed no damage to the hinges or latch anchors. Although the main door was not recovered, the airplane manufacturer issued a service bulletin on April 20, 2021, that required the latch mechanism to be inspected to ensure that the eight latch balls seated properly within their sockets without any clearance between the ball and socket. The service bulletin also required an inspection of the hinges at the next condition inspection and for the aluminum latch bodies to be replaced with structural stainless steel alloy bases.

Aircraft

Registration
N469KS
Reported as
Davis Dan B Lancair Evolution
Category
Airplane
Serial number
EVO-0058
Built
2015
Airframe hours
638
Engine
P&W Canada PT6A-135A, 750 horsepower, turbo prop
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Cc Aircraft Sales LLC
Registered owner
Cc Aircraft Sales LLC
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · December 17, 2020 · 51 hours before
Departed
FFZ · Mesa, AZ
Destination
OKB · Oceanside, CA
Flight plan
IFR
Equipment
Auto-pilot, Airframe parachute, ADS-B, Onboard weather, Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Data recorder

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
January 14, 2021
Seat
Left
Restraint
None
Flight hours
1,106 total · 52 in this make and model · 1,025 as pilot in command · 61 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Temperature
79 °F, dew point 28 °F
Altimeter
30.03 inHg
Observed at
KGYR, 9 nm away
METAR
KGYR 182147Z 00000KT 10SM SKC 26/M02 A3003

Docket · 7

The files NTSB released with the investigation on September 15, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.