DEN90IA012

NTSB incident investigation · Mcdonnell Douglas DC-9 · Monte Vista, CO · October 18, 1989

Incident · Minor injuriesIncident investigationFinal report
Date
October 18, 1989, 00:15 local (06:15 UTC)
Place
Monte Vista, CO
Injuries
1 minor, 102 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N922RWMcdonnell Douglas DC-9
Weather
Visual (VMC) · Night/dark
Status
Completed · report January 8, 1991
Report
Approved by Office Director
Safety recommendations
Yes
Case key
17849

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The poor inflight planning and decisions made by the flight crew following the failure of the number two generator constant speed drive unit. Contributing factors to the accident were the failure of the no. 2 generator constant speed drive unit and the crew's inadvertent shut down of the wrong generator which resulted in a complete loss of electrical power.

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/malfunctionCruise - normal
Electrical system,constant speed drive unit - leakFactor
Electrical system,constant speed drive unit - failure,totalFactor
Generator - inadvertent deactivationPilot in commandFactor
Apu - not attainedPilot in command
Aircraft manuals,system information - inadequate
Inadeq substantiation process,inadeq documentationCompany/operator mgmt
Electrical system - failure,totalFactor
OverrunLanding - roll
In-flight planning/decision - improperPilot in commandCause
Unsuitable terrain or takeoff/landing/taxi area - selectedPilot in commandCause
Lowering of flaps - not performedPilot in command
Landing gear,gear indicating system - inoperative
Insufficient standards/requirements,aircraftManufacturer

Analysis

While in cruise at FL350 the no. 2 generator constant speed drive (csd) failed and the crew inadvertently disconnected the no. 1 generator csd. Attempts to start the APU above the start envelope were made but aborted due to a hot start. A descent was made on emerg electrical power and a landing was made at an arpt which was inadequate for the acft. The crew chose to make a no flap apch and to lower landing gear by emerg method when both systems were operable by normal means. This decision was influenced by the lack of landing gear and flap position indicators when the acft is operated on battery power. The landing speed was fast and the acft departed the end of the rwy damaging the landing gear and the no. 1 engine. The crew failed to manually depressurize the acft and the evacuation was delayed until a knowledgeable passenger went to the cockpit and depressurized the acft. The operators acft operating manual did contain APU starting procedures but not an APU start envelope chart.

Aircraft

Registration
N922RW
Reported as
Mcdonnell Douglas DC-9
Category
Airplane
Serial number
47182
Airframe hours
61,931
Engine
P&W JT8D, 17,000 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Registered owner
Northwest Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · October 13, 1989 · 68 hours before
Departed
MSP · Minneapolis, MN
Destination
PHX · Phoenix, AZ
Flight plan
IFR
Airport
08V · Monte Vista, runway 2, 6,000 × 60 ft, asphalt

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
46
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
15,730 total · 12,335 in this make and model · 6,500 as pilot in command · 176 in the last 90 days · 70 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
150° at 8 knots
Visibility
15 statute miles
Lowest ceiling
3,500 ft overcast
Temperature
37 °F
Altimeter
30.00 inHg
Observed at
PUB, 100 nm away