DCA91MA023

NTSB accident investigation · Boeing 737-291 · Colorado Spgs, CO · March 3, 1991

Accident · FatalClass 1 · MajorFinal report
Date
March 3, 1991, 09:44 local (16:44 UTC)
Place
Colorado Spgs, CO
Injuries
25 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N999UABoeing 737-291
Weather
Visual (VMC) · Day
Status
Completed · report August 5, 1993
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19910303003669A
Case key
15948

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

A loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionApproach
Flight control,rudder surface - uncommandedCause
Flight control,rudder - jammedCause
Loss of control - in flightDescent - uncontrolled
Aircraft control - not possible
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

Executive Summary

On March 3, 1991, a United Airlines (UAL) Boeing 737, registration number N999UA, operating as flight 585, was on a scheduled passenger flight from Denver, Colorado, to Colorado Springs, Colorado. Visual meteorological conditions (VMC) prevailed at the time, and the flight was on an instrument flight rules (IFR) flight plan. Numerous witnesses reported that shortly after completing its turn onto the final approach course to runway 35 at Colorado Springs Municipal Airport (COS), about 0944 Mountain Standard Time, the airplane rolled steadily to the right and pitched nose down until it reached a nearly vertical attitude before hitting the ground in an area known as Widefield Park. The airplane was destroyed, and the 2 flight crewmembers, 3 flight attendants, and 20 passengers aboard were fatally injured.

Aircraft

Registration
N999UA
Reported as
Boeing 737-291
Category
Airplane
Serial number
22742
Airframe hours
26,050
Engine
P&W JT8D-17, 15,000 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Operator
United Airlines
Registered owner
United Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · May 27, 1990 · 2,046 hours before
Departed
DEN · Denver, CO
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Certificates
Commercial, Flight engineer, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
9,902 total · 1,732 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 23 knots, gusting 33
Visibility
99 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 9 °F
Altimeter
30.00 inHg
Observed at
COS, 3 nm away

FAA reports on this event · 1

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