DEN93IA044

NTSB incident investigation · Boeing 737-522 · Denver, CO · April 24, 1993

Incident · No injuriesIncident investigationFinal report
Date
April 23, 1993, 20:20 local (Apr 24, 1993, 02:20 UTC)
Place
Denver, CO
Injuries
133 uninjured
Damage
No damage
Phase of flight
Approach
Aircraft
N905UABoeing 737-522
Weather
Visual (VMC) · Dusk
Status
Completed · report September 20, 1994
Report
Approved by Office Director
FAA report
19930423017489I
Case key
11087

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 NTSB’s determination of the probable cause, and any contributing factors.

The pilot-in-command's failure to maintain adequate separation from the Boeing 757, and his failure to stay above the probable path of the Boeing's wake vortices, which resulted in the vortex encounter. Factors related to the accident were: the crosswind, and an inadequacy in ATC procedures concerning visual approaches of aircraft, behind and downwind from approaches of heavier aircraft to parallel or adjacent runways.

Analysis

On a visual approach to runway 26L, united flight 409, a Boeing 737, experienced an uncommanded roll of about 23 deg at an altitude of 882' AGL. The crew was able to correct the roll & made a go-around to an uneventful second approach & landing. The Boeing 737 was following a Boeing 757, which was on a visual approach to runway 26R. The two runways were 900' apart from centerline to centerline & the threshold of 26L was offset about 1300' east of 26R. According to data from the flight recorder, the wind at the onset of the incident was from the northwest at 5 to 10 knots. The surface wind was from 360 degrees at 10 knots. The two aircraft were 1.32 nautical miles apart in an offset trail position. Both aircraft were on 3 deg glide slopes. The wake vortices had settled about 100' & moved laterally toward the glide path of 26L. Weather data showed evidence of possible interaction between wake turbulence from the 757 & an outflow boundry, which was moving through the area.

Factual narrative

On Sunday, April 23, 1993, at 2020 mountain daylight time, a Boeing 737-522, N905UA, operated by United Airlines as flight 409 experienced an uncommanded roll at approximately 1,000 feet above ground level (AGL) while conducting a visual approach to runway 26 left at Stapleton International Airport, Denver, Colorado. There were no injuries to the 2 pilots, 3 flight attendants, or 128 passengers, and the aircraft was not damaged. The aircraft was being operated under the provisions of 14 CFR Part 121 when the incident occurred. Visual meteorological conditions prevailed and an IFR flight plan was on file. The flight originated from San Antonio, Texas, at 1830.

At the onset of the roll, according to the crew, maximum power was applied and a go around initiated. The roll was corrected by the crew and an uneventful landing was made on the next approach.

Radar data provided information that the incident aircraft was following a Boeing 757 which was conducting a visual approach to runway 26R. The two runways are 900 feet apart centerline to centerline and the incident aircraft was 1.34 miles (32 seconds)in trail behind the B757. According to flight recorder data from both aircraft, wind at the time of onset of the occurrence was from the northwest at 5 to 10 knots. The wind values changed to the northeast on the incident aircraft, during the occurrence, and reached a peak value of 30 knots. According to flight recorder data, the incident aircraft achieved a maximum deflection of 23.027 degrees left wing down during the uncommanded roll. This occurred at a radio altitude of 882 feet above ground level. A flight recorder factual report and radar data is attached.

In addition, research was conducted by NOAA in Boulder, Colorado, in the area of the interaction of wake turbulence with an outflow boundary. The research provided information that wake turbulence can be lifted up as an interaction with the boundary, and that an outflow boundary was moving through the area at the time of the incident.

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.

Vortex turbulence encounteredApproach - vfr pattern - final approach
Visual separation - inadequatePilot in commandCause
Weather condition - crosswindFactor
Wake turbulence - encounteredPilot in commandCause
Procedure inadequateFaa(other/organization)Factor

Aircraft

Registration
N905UA
Reported as
Boeing 737-522
Category
Airplane
Serial number
25005
Engine
GE CFM-56, 20,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
United Airlines
Departed
SAT · San Antonio, TX
Destination
DEN
Flight plan
IFR
Airport
DEN · Stapleton International, runway 26L, 10,004 × 150 ft

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
47
Certificates
Commercial, Airline transport, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
8,428 total · 1,731 in this make and model · 1,731 as pilot in command · 198 in the last 90 days · 73 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
360° at 10 knots, gusting 16
Visibility
50 statute miles
Lowest ceiling
27,000 ft broken
Temperature
59 °F, dew point 19 °F
Altimeter
29.00 inHg
Observed at
DEN

FAA reports on this event · 1

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