# NTSB FTW89MA047: Mcdonnell Douglas DC-9-32F, N935F, Salt Lake City, UT, February 9, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Major investigation · Final report
- Date: February 9, 1989, 01:00 local (08:00 UTC)
- Place: Salt Lake City, UT
- Location: 40.7608° N, 111.8910° W: Placed by OpenAirDocs: center of Salt Lake City, UT, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=40.7608&lon=-111.8910&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal, 1 uninjured
- Status: Completed, report July 23, 1991
- Report: Approved by Office Director
- NTSB case key (mKey): 22923
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW89MA047
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/22923/pdf
- Page: https://openairdocs.org/ntsb/FTW89MA047

## Probable cause

IMPROPER IN-FLIGHT PLANNING/DECISION BY THE CAPTAIN (PILOT-IN-COMMAND)  AND  HIS IMPROPER USE OF THE PORTABLE OXYGEN SYSTEM, WHICH RESULTED IN HIS INCAPACITATION DUE TO HYPOXIA.  FACTORS RELATED TO THE ACCIDENT WERE:  INADEQUATE MAINTENANCE/INSPECTION OF THE AIRCRAFT  BY COMPANY MAINTENANCE BY FAILING TO REINSTALL THE AFT PRESSURE BULKHEAD HATCH (INSPECTION DOOR) AND POOR CREW COORDINATION.

## Sequence of events

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

- Miscellaneous/other, climb
  - door,inspection - not installed (contributing factor)
  - maintenance,inspection - inadequate, company maintenance personnel (contributing factor)
  - fuselage,cabin - no pressure (contributing factor)
  - in-flight planning/decision - improper, pilot in command (cause)
  - climb - continued (contributing factor)
  - crew/group coordination - poor, pilot in command (contributing factor)
  - oxygen system - improper use of, pilot in command (cause)
  - incapacitation(anoxia/hypoxia), pilot in command (cause)

## Analysis

AS 1ST OFFICER (FO) WAS FLYING ACFT, DRG CLB AFTER TKOF, CABIN WOULDN'T PRESSURIZE. HE BGN LVL OFF AT 16,000', BUT CAPT ORDERED HIM TO CONT CLBG TO ASSIGNED FLT LVL (FL 330), WHILE HE (THE CAPT) WENT AFT TO FND PRBLM. FO DISLIKED THE ORDER,BUT COMPLIED RATHER THAN CONFRONT CAPT. CAPT LEFT COCKPIT WITH PORTABLE 'ON DEMAND' OXYGEN (O2) SYS, WHICH HAD 15 MIN SUPPLY OF O2. WHEN CAPT DIDN'T RTRN, FO TRIED SIGNALING HIM. THO RELUCTANT TO COUNTERMAND CAPT'S ORDER, FO MADE SERIES OF DSCNTS TO 13,000'. AFTER ABT 30 MIN, HE LEFT COCKPIT & FND CAPT UNCONSCIOUS & UNRESPONSIVE IN FWD CARGO AREA WITH O2 MASK ON HIS FACE. CAPT'S FOOT WAS ENTANGLED IN CARGO NET WHICH CVRD A PALLET. FO TRIED TO REVIVE CAPT, TO NO AVAIL, THENDECLARED EMERG & LNDD AT LUBBOCK. CAPT WAS RUSHED TO HOSPITAL, BUT WAS DEAD ON ARRIVAL. EXAM REVEALED AFT PRESSURE BULK-HEAD WAS NOT INSTALLED. IT HAD BEEN REMOVED FOR MAINT BFR FLT. PORTABLE O2 SYS WAS STILL FULL, INDCG CAPT HAD LITTLE OR NO USE OF O2; IT WAS TESTED & FUNCTIONED NMLY. GROUP OF 8 FORENSIC PATHOLOGISTS CONCLUDED CAPT DIED FM HYPOXIC HYPOXIA.

## Aircraft

- Registration: N935F (not matched to a registry record)
- Reported make and model: MCDONNELL DOUGLAS DC-9-32F
- Category: Airplane
- Serial number: 47220
- Airframe hours: 37823
- Engines: P&W JT8D-9A 14000 lbs thrust turbo fan
- Damage: No damage
- Flight: Part 121
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, January 13, 1989, 117 hours before
- Departed: KHIF, OGDEN, UT
- Destination: KSKF, SAN ANTONIO, TX
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 38; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; toxicology performed; flight hours: 11,000 total, 232 in this make and model, 10,000 as pilot in command, 152 in the last 90 days, 62 in the last 30 days, 5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: 120° at 8 knots
- Visibility: 15 statute miles
- Lowest ceiling: none
- Temperature: 19 °F
- Altimeter: 30.00 inHg

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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