# NTSB DCA92MA022: Douglas DC-8-63, N794AL, Swanton, OH, February 15, 1992

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: February 15, 1992, 03:26 local (08:26 UTC)
- Place: Swanton, OH
- Coordinates: 41.580909, -83.889991 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.5809&lon=-83.8900&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report December 16, 1993
- Report: Approved by Office Director
- NTSB office: Major Investigations Division
- NTSB case key (mKey): 15955
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA92MA022
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15955/pdf
- Page: https://openairdocs.org/ntsb/DCA92MA022

## Probable cause

THE FAILURE OF THE FLIGHTCREW TO PROPERLY RECOGNIZE OR RECOVER IN A TIMELY MANNER FROM THE UNUSUAL AIRCRAFT ATTITUDE THAT RESULTED FROM THE CAPTAIN'S APPARENT SPATIAL DISORIENTATION, RESULTING FROM PHYSIOLOGICAL FACTORS AND/OR A FAILED ATTITUDE DIRECTOR INDICATOR. (NTSB REPORT AAR-92/05)

## Sequence of events

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

- Loss of control - in flight, missed approach (ifr)
  - light condition - dark night
  - weather condition - low ceiling
  - weather condition - rain
  - weather condition - fog
  - flight/nav instruments,attitude director ind(adi) - undetermined (contributing factor)
  - aircraft control - not maintained, pilot in command (cause)
  - spatial disorientation, pilot in command (contributing factor)
- In flight collision with terrain/water, missed approach (ifr)

## Analysis

THE FIRST OFFICER HAD MADE TWO ILS APPROACHES, BUT, FOR UNDETERMINED REASONS, FAILED TO PROPERLY CAPTURE THE ILS LOCALIZER AND/OR GLIDESLOPE. DURING THE SECOND MISSED APPROACH, THE CAPTAIN ASSUMED CONTROL OF THE AIRPLANE; HOWEVER, HE APPARENTLY BECAME SPATIALLY DISORIENTED, AND INADVERTENTLY ALLOWED AN UNUSUAL ATTITUDE TO DEVELOP WITH BANK ANGLES UP TO 80 DEG AND PITCH ANGLES UP TO 25 DEG. THE FIRST OFFICER ASSUMED CONTROL AND BEGAN LEVELING THE WINGS AND RAISING THE NOSE OF THE AIRPLANE, BUT IMPACT OCCURRED BEFORE THE UNUSUAL ATTITUDE RECOVERY WAS COMPLETED. THE OPERABILITY OF THE CAPTAIN'S ATTITUDE DIRECTOR INDICATOR AT THE TIME CONTROL WAS LOST IS UNCERTAIN.

## Aircraft

- Registration: [N794AL](https://openairdocs.org/deregistered/N794AL-1993-03-29), registration cancelled 1993-03-29, S/N 45923 (OpenAirDocs)
- Reported make and model: DOUGLAS DC-8-63
- Category: Airplane
- Serial number: 45923
- Airframe hours: 4889
- Engines: P&W JT3D-7 turbo fan
- Damage: Destroyed
- Fire: On-Ground
- Flight: Part 121
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, February 13, 1992, 9 hours before
- Departed: SEA, SEATTLE, WA
- Destination: TOL, TOLEDO, OH
- Flight plan: IFR
- Airport: TOL, Toledo Express, runway 7, 10,600 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; airline transport, commercial; 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: 16,382 total, 2,382 in this make and model

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 90° at 13 knots
- Visibility: 2 statute miles
- Lowest ceiling: 400 ft overcast
- Temperature: 34 °F
- Altimeter: 29.00 inHg
- Observed at: TOL

## 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 19920215003069A](https://openairdocs.org/incident/19920215003069A), Feb 15, 1992: Doug DC863, Toledo, OH, Destroyed, 4 fatal. Lost control on IFR missed approach due PIC spatial disorientation and possible failed gyro. Extreme windshear.

## Other investigations on N794AL (1)

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.

- [NTSB NYC92IA030](https://openairdocs.org/ntsb/NYC92IA030), Nov 13, 1991: Douglas DC-8-63 (N794AL), Toledo, OH, incident, minor damage. Probable cause: THE FAILURE OF THE FLIGHT ENGINEER TO CONDUCT A PROPER PREFLIGHT INSPECTION AND ENSURE THE MAIN CARGO DOOR WAS FULLY CLOSED AND LOCKED. FACTORS RELATED TO THE ACCIDENT WERE THE DAMAGED WIRES IN THE…

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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