Individually Owned: 150,657
Corporate Owned: 137,281
N/A Airport
Aircraft Accident/Incident Report
Dodge City, Kansas 67801
Tuesady, June 10, 2003 10:30 MDT
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Incident |
| Event Date | 6/10/2003 |
| Event Day of the Week | Tuesday |
| Time of Event | 1030 |
| Event Time Zone | Mountain Daylight Time |
| Event City | Dodge City |
| Event State | KANSAS |
| Event Country | -- |
| Zipcode of the event site | 67801 |
| Event Date Year | 2003 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | -- |
| Event Location Longitude | -- |
| Event Location Airport | N/A |
| Event Location Nearest Airport ID | -- |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | Full |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1153 Central Daylight Time |
| Direction of event from weather observation facility (degrees) | 230 |
| Weather Observation Facility ID | DDC |
| Elevation of weather observation facility | 2594 |
| Distance of event from weather observation facility (units?) | 34 |
| Time Zone of the weather observation | CDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 23 |
| Dew Point at event time (in degress fahrenheit) | 14 |
| Wind Direction (degrees magnetic) | 30 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 13 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 29.86 |
| Density Altitude (feet) | 4209 |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Minor |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | 1 |
| Injury Total None | 173 |
| Injury Total Serious | -- |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 16203 |
| NTSB Notification Source | FAA COMM CTR |
| NTSB Notification Date | Jun 10 2003 12:00AM |
| NTSB Notification Time | 1007 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Sep 1 2004 7:08AM |
| User who most recently changed record | NTSB\MONR |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | Denver FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N704X |
| NTSB Number | DEN03IA101 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | None |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Boeing |
| Aircraft Model | 757-200 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 28163 |
| Certified Max Gross Weight | 255000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 174 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Jun 6 2003 12:00AM |
| Airframe hours since last inspection | 26 |
| Airframe Hours | 22891 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | ILFC VOLARE INC. |
| Aircraft Owner Street Address | 1999 Ave Of The Stars 39th Floor |
| Aircraft Owner City | Los Angeles |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 90067 |
| Operator is an individual? | No |
| Operator Name | TWA Airlines LLC. |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | TWAA |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | STL |
| Departure City | St Louis |
| Departure State | MO |
| Departure Country | USA |
| Departure Time | 955 |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | SNA |
| Destination City | Santa Ana |
| Destination State | CA |
| Destination Country | USA |
| Specific Phase of Flight | Cruise |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Apr 6 2004 1:07PM |
| User who most recently changed record | MCBM |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |