# NTSB DCA18CA056: Mcdonnell Douglas DC 9 33F, N935CE, Bethel, AK, December 23, 2017

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Data collection · Final report
- Date: December 23, 2017, 21:21 UTC
- Place: Bethel, AK
- Coordinates: 60.809642, -161.84996 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=60.8096&lon=-161.8500&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report August 23, 2019
- Report: Approved by Office Director
- NTSB office: Major Investigations Division
- NTSB case key (mKey): 96537
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA18CA056
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96537/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96537
- Page: https://openairdocs.org/ntsb/DCA18CA056

## Probable cause

failure of a cargo tie-down fastener, resulting in unsecured cargo striking the pressure bulkhead.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Fuselage: seat/cargo attach fitting](https://openairdocs.org/ntsb-findings/01035347): Aircraft › Aircraft structures · Failure (probable cause); cases with it: [Mcdonnell Douglas DC-9-33F, 1 case](https://openairdocs.org/ntsb-findings/01035347/cases.md?model=302207C), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/01035347/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Mcdonnell Douglas DC-9-33F, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=302207C), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md)

## Analysis

On December 23, 2017 at 1221 Alaska Standard Time (AkST) a Boeing/McDonnell-Douglas DC-9, registration N935CE, experienced a depressurization on initial climb from the Bethel, Alaska, airport (PABE.) The flight crew returned to Bethel and landed with no further incident. There were no injuries to the two flight crew and one cargo handler on board. The depressurization resulted from a pallet jack in the cargo compartment impacting the rear pressure bulkhead, resulting in substantial damage to the airplane. Inspection revealed a tie-down fastener for the pallet jack had pulled out.

## Factual narrative

On December 23, 2017 at 1221 Alaska Standard Time (AST), a Boeing/McDonnell-Douglas DC-9, N935CE, experienced a depressurization on initial climb from the Bethel, Alaska, airport (PABE.) The flight crew returned to Bethel and landed with no further incident. There were no injuries to the two flight crew members or one cargo handler on board. The depressurization resulted from a pallet jack in the cargo compartment impacting the rear pressure bulkhead, resulting in substantial damage to the airplane. Inspection revealed a tie-down fastener for the pallet jack had pulled out.

## Aircraft

- Registration: [N935CE](https://openairdocs.org/aircraft/N935CE), registered now, S/N 47413, built 1969 (OpenAirDocs)
- Reported make and model: MCDONNELL DOUGLAS DC 9 33F (33F)
- Registry model: [Mcdonnell Douglas DC-9-33F](https://openairdocs.org/model/mcdonnell-douglas-dc-9-33f) (registry code 302207C) (OpenAirDocs)
- Registry engine: [Pratt & Whitney JT8D-9 series](https://openairdocs.org/engine/pratt-whitney-jt8d-9-series) (registry code 52048, turbo-jet) (OpenAirDocs)
- Category: Airplane
- Serial number: 47413
- Year built: 1969
- Damage: Substantial damage
- Flight: Part 121
- Operator: Everts Air
- Registered owner: Tatonduk Outfitters Limited
- Airworthiness certificate: Standard, Transport
- Departed: PABE, Bethel, AK
- Destination: PANC, Anchorage, AK
- Flight plan: IFR
- Airport: PABE, Bethel, runway 19R, 6,400 × 150 ft, concrete
- Equipment: Electronic flight bag or handheld device, Data recorder

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 51; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review August 15, 2017; seat: left; restraint: 5-point; flight hours: 8,000 total, 2,000 in this make and model, 3,000 as pilot in command, 180 in the last 90 days, 80 in the last 30 days
- Co-pilot; age 31; injuries: none; flight instructor, commercial, airline transport; airplane ratings: single-engine land, single-engine sea; medical: class 1, without waivers/limitations; last flight review June 6, 2017; seat: right; restraint: 5-point; flight hours: 5,250 total, 450 in this make and model, 3,400 as pilot in command, 170 in the last 90 days, 50 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 90° at 15 knots, gusting 23
- Lowest ceiling: 12,000 ft broken
- Temperature: 39 °F, dew point 28 °F
- Altimeter: 29.57 inHg
- Observed at: PABE

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20171223024249A](https://openairdocs.org/incident/20171223024249A), Dec 23, 2017: Mcdonnell Douglas DC-9-33F, Bethel, AK, Substantial damage. 12-23-17 Aircraft N935CE operated by evert's air cargo (fxga) was departing Bethel AK bound for anchorage AK the crew heard a bang and the aircraft began to…

## Docket (8 files)

The files NTSB released with the investigation on September 12, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96537. 3.2 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475697&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Captain Statement (item 2, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475698&FileExtension=.PDF&FileName=Captain%20Statement-Master.PDF
- FO Statement (item 3, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475699&FileExtension=.PDF&FileName=FO%20Statement-Master.PDF
- Cargo Handler Statement (item 4, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475700&FileExtension=.PDF&FileName=Cargo%20Handler%20Statement-Master.PDF
- Photo of Damage 1 (item 5, .PDF, 1 photo, 305 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475701&FileExtension=.PDF&FileName=Photo%20of%20Damage%201-Master.PDF
- Photo of Damage 2 (item 6, .PDF, 1 photo, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475702&FileExtension=.PDF&FileName=Photo%20of%20Damage%202-Master.PDF
- Photo of Floor Widget (item 7, .PDF, 1 photo, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475703&FileExtension=.PDF&FileName=Photo%20of%20Floor%20Widget-Master.PDF
- Photo of Damage 3 (item 8, .PDF, 1 photo, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475704&FileExtension=.PDF&FileName=Photo%20of%20Damage%203-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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