# NTSB DCA91MA021: Mcdonnell Douglas DC-9-15, N565PC, Cleveland, OH, February 17, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: February 17, 1991, 00:19 local (05:19 UTC)
- Place: Cleveland, OH
- Coordinates: 41.489826, -81.67012 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.4898&lon=-81.6701&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report August 5, 1993
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 15947
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA91MA021.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15947/pdf
- Board report AAR9109 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9109.pdf
- Page: https://openairdocs.org/ntsb/DCA91MA021

## 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)

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, takeoff - initial climb
  - weather condition - snow (contributing factor)
  - wing - ice (cause)
  - aircraft preflight - not performed, pilot in command (cause)
  - ice/frost removal from aircraft - not performed, pilot in command (cause)
  - inadequate training, company/operator management (cause)
  - acft/equip,inadequate aircraft manuals, manufacturer (cause)
  - acft/equip,inadequate aircraft manuals, faa(other/organization) (cause)
  - stall - inadvertent, pilot in command
- In flight collision with terrain/water, takeoff - initial climb

## Analysis

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.

## Aircraft

- Registration: [N565PC](https://openairdocs.org/deregistered/N565PC-1991-07-09), registration cancelled 1991-07-09, S/N 47240 (OpenAirDocs)
- Reported make and model: MCDONNELL DOUGLAS DC-9-15
- Registry model: [Mcdonnell Douglas DC-9-15F](https://openairdocs.org/model/mcdonnell-douglas-dc-9-15f) (registry code 302203K) (OpenAirDocs)
- Category: Airplane
- Serial number: 47240
- Engines: P&W JT8D-7B 13000 lbs thrust turbo jet
- Damage: Destroyed
- Fire: On-Ground
- Flight: Part 121
- Operator: Ryan International Airlines
- Registered owner: Wilmington Trust Company
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, January 2, 2000
- Departed: CLE
- Destination: IND, INDIANAPOLIS, IN
- Flight plan: IFR
- Airport: CLE, Cleveland-Hopkins Int'L, runway 23L, 8,998 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 46; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 10,505 total, 505 in this make and model

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 220° at 14 knots
- Visibility: 1 statute miles
- Lowest ceiling: 1,500 ft
- Temperature: 23 °F, dew point 19 °F
- Altimeter: 29.00 inHg
- Observed at: CLE

## 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 19910217002609A](https://openairdocs.org/incident/19910217002609A), Feb 17, 1991: Doug DC915F, Cleveland, OH, Destroyed, 2 fatal. Lost control on takeoff. Rolled nearly inverted and crashed on airport. Failed to deice. Type susceptible to ice.

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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