DCA09MA021

NTSB accident investigation · Boeing 737-524 · Denver, CO · December 21, 2008

Accident · Serious injuriesClass 1 · MajorFinal report
Date
December 20, 2008, 18:18 local (Dec 21, 2008, 01:18 UTC)
Place
Denver, CO
Injuries
6 serious, 41 minor, 68 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N18611Boeing 737-524
Defining event
Takeoff: Runway excursion
Weather
Visual (VMC)
Status
Completed · report August 17, 2010
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20081220853549A
Case key
69602

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

The captain’s cessation of right rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the excursion, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience. Contributing to the accident were the following factors: 1) an air traffic control system that did not require or facilitate the dissemination of key, available wind information to the air traffic controllers and pilots; and 2) inadequate crosswind training in the airline industry due to deficient simulator wind gust modeling.

Findings · 10

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.

Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedBoeing 737-524: 1 caseAll aircraft: 3,958 casesProbable cause
Performance/control parameters: crosswind correctionAircraft › Aircraft oper/perf/capability · Not attained/maintainedBoeing 737-524: 1 caseAll aircraft: 184 casesProbable cause
Wind: crosswindEnvironmental issues › Conditions/weather/phenomena · Response/compensationBoeing 737-524: 1 caseAll aircraft: 1,008 casesProbable cause
Action: incomplete actionPersonnel issues › Action/decision · PilotBoeing 737-524: 1 caseAll aircraft: 105 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotBoeing 737-524: 1 caseAll aircraft: 9,295 casesProbable cause
Wind: crosswindEnvironmental issues › Conditions/weather/phenomena · Availability of related infoBoeing 737-524: 1 caseAll aircraft: 1,008 casesProbable cause
TrainingOrganizational issues › Support/oversight/monitoring · Not specifiedBoeing 737-524: 1 caseAll aircraft: 26 casesProbable cause
Equipment/furnishingsAircraft › Aircraft systems · Damaged/degradedBoeing 737-524: 1 caseAll aircraft: 12 cases

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 Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10/04. On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of whom were lap-held children) were uninjured. The airplane was substantially damaged. The scheduled, domestic passenger flight, operated under the provisions of 14 Code of Federal Regulations Part 121, was departing DEN and was destined for George Bush Intercontinental Airport, Houston, Texas. At the time of the accident, visual meteorological conditions prevailed, with strong and gusty winds out of the west. The flight operated on an instrument flight rules flight plan.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10/04. On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of whom were lap-held children) were uninjured. The airplane was substantially damaged. The scheduled, domestic passenger flight, operated under the provisions of 14 Code of Federal Regulations Part 121, was departing DEN and was destined for George Bush Intercontinental Airport, Houston, Texas. At the time of the accident, visual meteorological conditions prevailed, with strong and gusty winds out of the west. The flight operated on an instrument flight rules flight plan.

Aircraft

Registration
N18611
Reported as
Boeing 737-524
Category
Airplane
Serial number
27324
Engines
CFM Intl. CFM56 SERIES, 2,200 horsepowerCFM Intl. CFM56 SERIES, 2,200 horsepower
Damage
Substantial damage
Fire
On-Ground
Flight
Part 121
Operator
Continental Airlines Inc
Registered owner
Wells Fargo Bank Northwest Na Trustee
Airworthiness certificate
Standard, Transport
Departed
KDEN · Denver, CO
Destination
KIAH · Houston, TX
Flight plan
IFR
Airport
KDEN · Denver International Airport, runway 34R, 12,000 × 150 ft, concrete

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Certificate
Airline transport
Medical
Class 1
Flight hours
13,100 total · 6,300 in this make and model · 915 in the last 90 days · 81 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
34
Medical
Class 1
Flight hours
8,000 total · 1,500 in this make and model · 918 in the last 90 days · 34 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC)
Wind
270° at 27 knots, gusting 42
Observed at
KDEN

Docket · 91

The files NTSB released with the investigation on July 17, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 111 MB in all.

Operations 2 and Human Performance 14 - Factual Report of Group ChairmenItem 1 · .PDF · 499 KBOperations 2 and Human Performance 14 - Attachment 1 Interview SummariesItem 2 · .PDF · 387 KBOperations 2 and Human Performance 14 - Attachment 2 - Crew StatementsItem 3 · .PDF · 178 KBOperations 2 and Human Performance 14 - Attachment 3 Operational Study FINALItem 4 · .PDF · 37 KBOperations 2 and Human Performance 14 - Attachment 4 - Flight PapersItem 5 · .PDF · 415 KBOperations 2 and Human Performance 14 - Attachment 5 - CAL's 737 Flight Manual ExcerptsItem 6 · .PDF · 900 KBOperations 2 and Human Performance 14 - Attachment 6 Operational Information Requested by NTSBItem 7 · .PDF · 45 KBOperations 2 and Human Performance 14 - Addendum 1Item 8 · .PDF · 18 KBOperations 2 and Human Performance 14 - Addendum 2, Interviews with 2006 RTO CrewItem 9 · .PDF · 60 KBOperations 2 and Human Performance 14 - Addendum 3, Back-drive simulation studyItem 10 · .PDF · 91 KBOperations 2 and Human Performance 14 - Addendum 4 and Corrections to the Factual ReportItem 11 · .PDF · 28 KBOperations 2 and Human Performance 14 - Addendum 5, Boeing responses to questions about B-737 crosswind guidelinesItem 12 · .PDF · 23 KBOperations 2 and Human Performance 14 - Addendum 6, Continental Airlines Prior B-737 Crosswind Takeoff GuidelinesItem 13 · .PDF · 283 KBOperations 2 and Human Performance 14 - Addendum 7, B-737 Actual Demonstrated Crosswind Values for Takeoff on a Dry RunwayItem 14 · .PDF · 16 KBOperations 2 and Human Performance 14 - Addendum 8, Data from 18 high crosswind takeoffs provided by Continental AirlinesItem 15 · ZIP · 297 KBATC 3 - Factual Report of Group Chairman (see also addendums 1 and 2 dated 1/8/10 and 6/14/10)Item 16 · .PDF · 879 KBATC 3 - Attachment 1 - DEN ATC Position LogsItem 17 · .PDF · 4.6 MBATC 3 - Attachment 2 - Flight Progress StripsItem 18 · .PDF · 37 KBATC 3 - Attachment 3 - ATC TranscriptsItem 19 · .PDF · 774 KBATC 3 - Attachment 4 - ATCT Daily Record of Facility Operation 12-20-08 to 12-21-08Item 20 · .PDF · 119 KBATC 3 - Attachment 5 - Controller StatementsItem 21 · .PDF · 209 KBATC 3 - Attachment 6 - Denver International Airport Noise Abatement RuleItem 22 · .PDF · 52 KBATC 3 - Attachment 7 - Denver International Airport Layout PlanItem 23 · .PDF · 3.5 MBATC 3 - Attachment 8 - DIA comment letter to ATC FactualItem 24 · .PDF · 193 KBATC 3 - Addendum 1 - ATC Factual - ATC Training (dated 1/8/10)Item 25 · .PDF · 30 KBATC 3 - Addendum 2, ATC Factual (dated 6/14/10)Item 26 · .PDF · 21 KBMeteorology 5 - Factual Report of Group ChairmanItem 27 · .PDF · 2.6 MBMeteorology 5 - Attachment 1 - ASOS Sensor LocationsItem 28 · .PDF · 51 KBMeteorology 5 - Attachment 2 - ASOS Users GuideItem 29 · .PDF · 867 KBMeteorology 5 - Attachment 3 - ASOS IFWS AlgorithmItem 30 · .PDF · 22 KBMeteorology 5 - Attachment 4 - LLWAS Wind Sensor PlotItem 31 · .PDF · 4.2 MBMeteorology 5 - Attachment 5 - LLWAS Wind Sensor DataItem 32 · .PDF · 3.2 MBMeteorology 5 - Attachment 6 - LLWAS AlertsItem 33 · .PDF · 1.2 MBMeteorology 5 - Attachment 7 - TDWR Letter FAAItem 34 · .PDF · 44 KBMeteorology 5 - Attachment 8 - ITWS ImagesItem 35 · .PDF · 2.9 MBMeteorology 5 - Attachment 9 - Bunker StatementItem 36 · .PDF · 21 KBMeteorology 5 - Attachment 6 NCAR studyItem 37 · .PDF · 1.1 MBMeteorology 5 - Attachment 10 - COA1404 Dispatcher ResponsesItem 38 · .PDF · 34 KBMeteorology 5 - Addendum 1Item 39 · .PDF · 3.3 MBSurvival Factors Group Factual ReportItem 40 · .PDF · 432 KBSurvival Factors Factual Report - Addenda/Errata 1Item 41 · .PDF · 20 KBSurvival Factors Factual Report - Addenda/Errata 2Item 42 · .PDF · 12 KBSurvival Factors Factual Report - Attachment 1A - Passenger QuestionnairesItem 43 · .PDF · 4.4 MBSurvival Factors Factual Report - Attachment 1B - Passenger QuestionnairesItem 44 · .PDF · 4.4 MBSurvival Factors Factual Report - Attachment 1C - Passenger QuestionnairesItem 45 · .PDF · 4.3 MBSurvival Factors Factual Report - Attachment 1D - Passenger QuestionnairesItem 46 · .PDF · 4.4 MBSurvival Factors Factual Report - Attachment 1E - Passenger QuestionnairesItem 47 · .PDF · 4.0 MBSurvival Factors Factual Report - Attachment 1F - Passenger QuestionnairesItem 48 · .PDF · 4.0 MBSurvival Factors Factual Report - Attachment 2 - ARFF and Operations StatementsItem 49 · .PDF · 4.0 MBSurvival Factors Factual Report - Attachment 3 - Denver Health Response ChronologyItem 50 · .PDF · 49 KBSurvival Factors Factual Report - Attachment 4 - Passenger Briefing CardItem 51 · .PDF · 1.3 MBSurvival Factors Factual Report - Attachment 5 - PhotographsItem 52 · .PDF · 1.2 MBSurvival Factors Miscellaneous - G4B Galley Service BulletinItem 53 · .PDF · 190 KBStructures 7 - Factual Report of Group Chairman (with 5 embedded photos)Item 54 · .PDF · 718 KBStructures 7 - Attachment 1, Winglet Installation FAA Form 337Item 55 · .PDF · 241 KBStructures 7 - Attachment 2, EA5730-02222 Rib Installation PaperworkItem 56 · .PDF · 193 KBPowerplants 8 - Factual Report of Group Chairman with 23 photos embeddedItem 57 · .PDF · 4.9 MBSystems 9 - Factual Report of Group Chairman (with 11 photos embedded )Item 58 · .PDF · 1.4 MBSystems 9 - Errata 1 to Factual Report of Group ChairmanItem 59 · .PDF · 15 KBFlight Data Recorder 10 - Specialist's Factual ReportItem 60 · .PDF · 199 KB
All 91 files on NTSB’s docket

FAA reports on this event · 1

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