FTW96FA118

NTSB accident investigation · McDonnell Douglas DC-9-32 · Houston, TX · February 19, 1996

Accident · Minor injuriesClass 1 · FieldFinal report
Date
February 19, 1996, 09:02 local (15:02 UTC)
Place
Houston, TX
Injuries
12 minor, 75 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N10556McDonnell Douglas DC-9-32
Weather
Visual (VMC) · Day
Status
Completed · report May 2, 1997
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Safety recommendations
Yes
FAA report
19960219003889A
Case key
19624

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

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Probable cause

the captain's decision to continue the approach contrary to Continental Airlines (COA) standard operating procedures that mandate a go-around when an approach is unstabilized below 500 feet or a ground proximity warning system alert continues below 200 feet above field elevation. The following factors contributed to the accident: (1) the flightcrew's failure to properly complete the in-range checklist, which resulted in a lack of hydraulic pressure to lower the landing gear and deploy the flaps; (2) the flightcrew's failure to perform the landing checklist and confirm that the landing gear was extended; (3) the inadequate remedial actions by COA to ensure adherence to standard operating procedures; and (4) the Federal Aviation Administration's inadequate oversight of COA to ensure adherence to standard operating procedures. (NTSB Report AAR-97/01)

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.

Wheels up landingLanding - flare/touchdown
Checklist - not complied withFlightcrewFactor
Hydraulic system - not selectedFlightcrew
Checklist - not usedFlightcrewFactor
Gear down and locked - not verifiedFlightcrewFactor
Go-around - not performedPilot in commandCause
Inadequate substantiation processCompany/operator mgmtFactor
Inadequate surveillance of operationFaa(organization)Factor
Wheels up landing - inadvertent

Analysis

The airplane landed wheels up and slid 6,850 feet before coming to rest in grass about 140 feet left of the runway centerline. The cabin began to fill with smoke, and the airplane was evacuated. Investigation showed that because the captain had omitted the 'Hydraulics' item on the in-range checklist and the first officer failed to detect the the error, hydraulic pressure was not available to lower the landing gear and deploy the flaps. Both the captain and the first officer recognized that the flaps had not extended after the flaps were selected to 15 deg. The pilots then failed to perform the landing checklist and to detect the numerous cues alerting them to the status of the landing gear because of their focus on coping with the flap extension problem and the high level of workload as a result of the rapid sequence of events in the final minute of flight. The first officer attempted to communicate his concern about the excessive speed of the approach to the captain. There were deficiencies in Continental Airlines' (COA) oversight of its pilots and the principal operations inspector's oversight of COA. COA was aware of inconsistencies in flightcrew adherence to standard operating procedures within the airline; however, corrective actions taken before the accident had not resolved this problem.

Factual narrative

See Aircraft Accident Report, "Wheels-Up Landing, Continental Airlines Flight 1943, Douglas DC-9-32, N10556, Houston, Texas, February 19, 1996," NTSB/AAR-97/01.

Aircraft

Registration
N10556
Reported as
McDonnell Douglas DC-9-32
Category
Airplane
Serial number
47243
Airframe hours
63,162
Engine
P&W JT8D-9A, 14,500 lbs thrust, turbo fan
Damage
Substantial damage
Fire
On-Ground
Flight
Part 121
Operator
Continental Airlines, Inc.
Registered owner
First Security Bank Of Utah
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 17, 1996 · 11 hours before
Departed
DCA · Washington, DC
Destination
IAH
Flight plan
IFR
Airport
IAH · Houston Intercontinental, runway 27, 9,999 × 150 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
50
Certificate
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
17,500 total · 220 in this make and model · 6,000 as pilot in command · 87 in the last 90 days · 29 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 12 knots
Visibility
10 statute miles
Lowest ceiling
1,800 ft broken
Temperature
68 °F, dew point 63 °F
Altimeter
29.00 inHg
Observed at
IAH

Docket · 42

The files NTSB released with the investigation on January 8, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 45.4 MB in all.

Notice of Opening of Public DocketItem 1 · .PDF · 9 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 2 · .PDF · 575 KBSurvival Factors 6A - Specialist's Factual ReportItem 3 · .PDF · 5.6 MBFlight Data Recorder 10A - Specialist's Factual ReportItem 4 · .PDF · 762 KBCockpit Voice Recorder 12A - Specialist's Factual ReportItem 5 · .PDF · 1.0 MBHuman Performance 14A - Investigator's Factual ReportItem 6 · .PDF · 2.6 MBInvestigator-In-Charge's Factual ReportItem 7 · .PDF · 1.8 MBWitness Statements (5)Item 8 · .PDF · 228 KBMaps or Charts of Accident AreaItem 9 · .PDF · 90 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 10 · .PDF · 99 KBTranscript of Interview of IACP PersonnelItem 11 · .PDF · 3.8 MBTranscript of Interview of Glen ShellhouseItem 12 · .PDF · 2.9 MBTranscript of Interview of Thomas C. TomburoItem 13 · .PDF · 844 KBTranscript of Interview of John Keeney, Jr.Item 14 · .PDF · 6.4 MBTranscript of Interview of Clarence D. McLeanItem 15 · .PDF · 1.6 MBTranscript of Interview of Deborah McCoyItem 16 · .PDF · 5.2 MBTranscript of Interview of Charles HillItem 17 · .PDF · 624 KBTranscript of Interview of George McKenzieItem 18 · .PDF · 2.1 MBTranscript of Interview of Ronald OsbornItem 19 · .PDF · 2.4 MBTranscript of Interview of Fred AbbottItem 20 · .PDF · 3.0 MBCOA DC-9 Normal Checklist and Excerpts from Expanded ChecklistItem 21 · .PDF · 481 KBExcerpts from COA DC-9 Flight ManualItem 22 · .PDF · 520 KBCOA Training Records for Captain and First OfficerItem 23 · .PDF · 267 KBCaptain's Line Check Report Dated 07/17/95Item 24 · .PDF · 144 KBPhoto 1: The airplane in the grass off to the left side of runway 27.Item 25 · .PDF · 37 KBPhoto 2: The airplane's initial touchdown point. The scrape mark was continuous for 6,850 feet, from this point to the airplane.Item 26 · .PDF · 46 KBPhoto 3: The scrape mark as it diverged off the left side of the runway.Item 27 · .PDF · 27 KBPhoto 4: The airplane came to rest on a magnetic heading of 255 degrees. Photo courtesy of FAA. No negative.Item 28 · .PDF · 38 KBPhoto 5: Left inboard main landing gear door.Item 29 · .PDF · 59 KBPhoto 6: Erosion of the outer skin of the left inboard main landing gear door.Item 30 · .PDF · 46 KBPhoto 7: Right inboard main landing gear door. Photo courtesy of FAA. No negative.Item 31 · .PDF · 69 KBPhoto 8: Left forward nose gear door. Photo courtesy of FAA. No negative.Item 32 · .PDF · 72 KBPhoto 9: Nose gear. Note that both right nose gear doors remained attached. Photo courtesy of Continental Airlines. No negative.Item 33 · .PDF · 33 KBPhoto 10: Damage to lower fuselage of airplane. Photo courtesy of Continental Airlines. No negative.Item 34 · .PDF · 38 KBPhoto 11: Closeup of damage to the lower fuselage due to contact erosion. Photo courtesy of Continental Airlines. No negative.Item 35 · .PDF · 41 KBPhoto 12: Left main landing gear. Note the undamaged outboard gear door. Photo courtesy of Continental Airlines. No negative.Item 36 · .PDF · 53 KBPhoto 13: Cockpit throttle quadrant with flap handle positioned to 50 degrees.Item 37 · .PDF · 54 KBPhoto 14: Cockpit center instrument panel with gear handle in the down position. Note the hydraulic switches in the "cruise" configuration (lower right corner of photo).Item 38 · .PDF · 63 KBPhoto 15: Cockpit overhead panel. Note the broken safety wire on GPWS flap override switch (upper left corner of photo).Item 39 · .PDF · 65 KBOther Pertinent Forms and Reports - First Officer's Written Statement 01/27/97Item 40 · .PDF · 645 KBOther Pertinent Forms and Reports - Party Submission from IACPItem 41 · .PDF · 332 KBStatement of Party Representatives to NTSB InvestigationItem 42 · .PDF · 517 KB

FAA reports on this event · 1

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