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NTSB Report
February 17, 1991 · Mcdonnell Douglas DC-9-15 · N565PC
Cleveland, OH
Overview
Report Status
Probable Cause
Event Type
Accident
Date
February 17, 1991
Injury Outcomes
2 injuries (2 fatalities)
Location
Cleveland, OH
Aircraft
Mcdonnell Douglas DC-9-15
Tail Number
N565PC
Operator
Ryan International Airlines
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
DCA91MA021
THE FLIGHT HAD FLOWN THROUGH WEATHER CONDUCIVE TO AIRFRAME ICE ABOUT 40 MIN PRIOR TO THE ACCIDENT DURING DESCENT INTO CLEVELAND. DURING THE 35-MINUTE TURNAROUND AT CLEVELAND THE CREW DID NOT EXIT THE AIRPLANE TO CONDUCT AN EXTERIOR PREFLIGHT INSPECTION TO VERIFY THAT THE WINGS WERE FREE OF ICE CONTAMINATION. IT WAS SNOWING WHILE THEY WERE ON THE GROUND. THE AIRPLANE STALLED AND ROLLED INTO THE GROUND IMMEDIATELY AFTER TAKEOFF. THERE WAS NO OPERATOR REQUIREMENT FOR THE PREFLIGHT. THE FLIGHT HAD NOT BEEN GIVEN TRAINING REGARDING THE EFFECTS OF WING CONTAMINATION ON THE AIRPLANE. THE FAA AND THE MANUFACTURER HAVE BEEN AWARE FOR SEVERAL YEARS OF THE PROPENSITY OF THE DC-9 SERIES 10 TO THE LOSS OF CONTROL CAUSED BY WING CONTAMINATION, BUT NEITHER OF THEM TOOK POSITIVE ACTION TO INCLUDE RELATED INFORMATION IN THE APPROVED AIRPLANE FLIGHT MANUAL.
NTSB Probable Cause
THE FAILURE OF THE FLIGHTCREW TO DETECT AND REMOVE ICE CONTAMINATION ON THE AIRPLANE'S WINGS, WHICH WAS LARGELY A RESULT OF A LACK OF APPROPRIATE RESPONSE BY THE FEDERAL AVIATION ADMINISTRATION, DOUGLAS AIRCRAFT COMPANY, AND RYAN INTERNATIONAL AIRLINES TO THE KNOWN CRITICAL EFFECT THAT A MINUTE AMOUNT OF CONTAMINATION HAS ON THE STALL CHARACTERISTICS OF THE DC-9 SERIES 10 AIRPLANE. THE ICE CONTAMINATION LED TO WING STALL AND LOSS OF CONTROL DURING THE ATTEMPTED TAKEOFF. (NTSB REPORT AAR-91/09)
Full Narrative
THE FLIGHT HAD FLOWN THROUGH WEATHER CONDUCIVE TO AIRFRAME ICE ABOUT 40 MIN PRIOR TO THE ACCIDENT DURING DESCENT INTO CLEVELAND. DURING THE 35-MINUTE TURNAROUND AT CLEVELAND THE CREW DID NOT EXIT THE AIRPLANE TO CONDUCT AN EXTERIOR PREFLIGHT INSPECTION TO VERIFY THAT THE WINGS WERE FREE OF ICE CONTAMINATION. IT WAS SNOWING WHILE THEY WERE ON THE GROUND. THE AIRPLANE STALLED AND ROLLED INTO THE GROUND IMMEDIATELY AFTER TAKEOFF. THERE WAS NO OPERATOR REQUIREMENT FOR THE PREFLIGHT. THE FLIGHT HAD NOT BEEN GIVEN TRAINING REGARDING THE EFFECTS OF WING CONTAMINATION ON THE AIRPLANE. THE FAA AND THE MANUFACTURER HAVE BEEN AWARE FOR SEVERAL YEARS OF THE PROPENSITY OF THE DC-9 SERIES 10 TO THE LOSS OF CONTROL CAUSED BY WING CONTAMINATION, BUT NEITHER OF THEM TOOK POSITIVE ACTION TO INCLUDE RELATED INFORMATION IN THE APPROVED AIRPLANE FLIGHT MANUAL.
Flight
Event TypeAccident
Event Time00:19 EST
Nearest AirportCleveland-Hopkins Int'L (0nm)
Runway23L
Runway Length8998 ft
Runway Width150 ft
Flight Plan FiledIFR
Aircraft FireGrd
Aircraft ExplosionNo
Aircraft
AircraftMcdonnell Douglas DC-9-15
Tail NumberN565PC
Aircraft CategoryAir
DamageDestroyed
OperatorRyan International Airlines
Operating RulePart 121
Engines2
Engine TypeTurbojet
Engine DetailsP&W · JT8D-7B · Turbojet · 13000
Seats3
People & Injuries
Injury Summary2 injuries (2 fatalities)
Fatal2
Serious0
Minor0
Uninjured0
Total2
Crew 1Age 46 · First Class
Conditions
ConditionsIMC
LightDark Night
Wind220° @ 14 kt
Visibility1 sm
Ceiling1500 ft
Temperature / Dew Point23 C / 19 C
Altimeter29.00 inHg
Observation Time04:50
Weather SourceWFAC