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February 9, 1989 · Mcdonnell Douglas DC-9-32F · N935F

Salt Lake City, UT

Overview

Report Status
Probable Cause
Event Type
Accident
Date
February 9, 1989
Injury Outcomes
1 injury (1 fatality), 1 uninjured
Location
Salt Lake City, UT
Aircraft
Mcdonnell Douglas DC-9-32F
Tail Number
N935F
Injuries
Fatal
NTSB Number
FTW89MA047

AS 1ST OFFICER (FO) WAS FLYING ACFT, DRG CLB AFTER TKOF, CABIN WOULDN'T PRESSURIZE. HE BGN LVL OFF AT 16,000', BUT CAPT ORDERED HIM TO CONT CLBG TO ASSIGNED FLT LVL (FL 330), WHILE HE (THE CAPT) WENT AFT TO FND PRBLM. FO DISLIKED THE ORDER,BUT COMPLIED RATHER THAN CONFRONT CAPT. CAPT LEFT COCKPIT WITH PORTABLE 'ON DEMAND' OXYGEN (O2) SYS, WHICH HAD 15 MIN SUPPLY OF O2. WHEN CAPT DIDN'T RTRN, FO TRIED SIGNALING HIM. THO RELUCTANT TO COUNTERMAND CAPT'S ORDER, FO MADE SERIES OF DSCNTS TO 13,000'. AFTER ABT 30 MIN, HE LEFT COCKPIT & FND CAPT UNCONSCIOUS & UNRESPONSIVE IN FWD CARGO AREA WITH O2 MASK ON HIS FACE. CAPT'S FOOT WAS ENTANGLED IN CARGO NET WHICH CVRD A PALLET. FO TRIED TO REVIVE CAPT, TO NO AVAIL, THENDECLARED EMERG & LNDD AT LUBBOCK. CAPT WAS RUSHED TO HOSPITAL, BUT WAS DEAD ON ARRIVAL. EXAM REVEALED AFT PRESSURE BULK-HEAD WAS NOT INSTALLED. IT HAD BEEN REMOVED FOR MAINT BFR FLT. PORTABLE O2 SYS WAS STILL FULL, INDCG CAPT HAD LITTLE OR NO USE OF O2; IT WAS TESTED & FUNCTIONED NMLY. GROUP OF 8 FORENSIC PATHOLOGISTS CONCLUDED CAPT DIED FM HYPOXIC HYPOXIA.

NTSB Probable Cause

IMPROPER IN-FLIGHT PLANNING/DECISION BY THE CAPTAIN (PILOT-IN-COMMAND) AND HIS IMPROPER USE OF THE PORTABLE OXYGEN SYSTEM, WHICH RESULTED IN HIS INCAPACITATION DUE TO HYPOXIA. FACTORS RELATED TO THE ACCIDENT WERE: INADEQUATE MAINTENANCE/INSPECTION OF THE AIRCRAFT BY COMPANY MAINTENANCE BY FAILING TO REINSTALL THE AFT PRESSURE BULKHEAD HATCH (INSPECTION DOOR) AND POOR CREW COORDINATION.

Full Narrative

AS 1ST OFFICER (FO) WAS FLYING ACFT, DRG CLB AFTER TKOF, CABIN WOULDN'T PRESSURIZE. HE BGN LVL OFF AT 16,000', BUT CAPT ORDERED HIM TO CONT CLBG TO ASSIGNED FLT LVL (FL 330), WHILE HE (THE CAPT) WENT AFT TO FND PRBLM. FO DISLIKED THE ORDER,BUT COMPLIED RATHER THAN CONFRONT CAPT. CAPT LEFT COCKPIT WITH PORTABLE 'ON DEMAND' OXYGEN (O2) SYS, WHICH HAD 15 MIN SUPPLY OF O2. WHEN CAPT DIDN'T RTRN, FO TRIED SIGNALING HIM. THO RELUCTANT TO COUNTERMAND CAPT'S ORDER, FO MADE SERIES OF DSCNTS TO 13,000'. AFTER ABT 30 MIN, HE LEFT COCKPIT & FND CAPT UNCONSCIOUS & UNRESPONSIVE IN FWD CARGO AREA WITH O2 MASK ON HIS FACE. CAPT'S FOOT WAS ENTANGLED IN CARGO NET WHICH CVRD A PALLET. FO TRIED TO REVIVE CAPT, TO NO AVAIL, THENDECLARED EMERG & LNDD AT LUBBOCK. CAPT WAS RUSHED TO HOSPITAL, BUT WAS DEAD ON ARRIVAL. EXAM REVEALED AFT PRESSURE BULK-HEAD WAS NOT INSTALLED. IT HAD BEEN REMOVED FOR MAINT BFR FLT. PORTABLE O2 SYS WAS STILL FULL, INDCG CAPT HAD LITTLE OR NO USE OF O2; IT WAS TESTED & FUNCTIONED NMLY. GROUP OF 8 FORENSIC PATHOLOGISTS CONCLUDED CAPT DIED FM HYPOXIC HYPOXIA.

Flight

Event TypeAccident
Event Time01:00 MST
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftMcdonnell Douglas DC-9-32F
Tail NumberN935F
Aircraft CategoryAir
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsP&W · JT8D-9A · Turbofan · 14000
Seats2

People & Injuries

Injury Summary1 injury (1 fatality), 1 uninjured
Fatal1
Serious0
Minor0
Uninjured1
Total2
Crew 1Age 38 · First Class

Conditions

ConditionsVMC
LightDark Night
Wind120° @ 8 kt
Visibility15 sm
CeilingNone
Temperature / Dew Point19 C / 0 C
Altimeter30.00 inHg
Weather SourcePILO

Appendix: Source Data