# NTSB NYC94LA062: Douglas DC-8-61, N817CK, Covington, KY, March 15, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 15, 1994, 07:27 local (12:27 UTC) - Place: Covington, KY - Location: 39.6657° N, 84.0171° W: Placed by OpenAirDocs from NTSB’s distance and direction from CINCINNATI/NORTHERN KENTUCKY INTL (CVG), within about 17 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=39.6657&lon=-84.0171&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 2 uninjured - Status: Completed, report April 7, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 38740 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC94LA062 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38740/pdf - Page: https://openairdocs.org/ntsb/NYC94LA062 ## Probable cause THE CAPTAIN'S IMPROPER DECISION TO CONDUCT FLIGHT AT HIGH ALTITUDE IN AN UNPRESSURIZED AIRPLANE, WHICH RESULTED IN HIS INCAPACITION FROM DEPRESSURIZATION SICKNESS. A FACTOR RELATED TO THE ACCIDENT WAS: MAINTENANCE PERSONNEL FAILED TO PROPERLY SECURE THE EMERGENCY EXIT DOOR AFTER IT WAS REMOVED TO PERFORM MAINTENANCE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, climb - to cruise - door,emergency exit - not secured (contributing factor) - maintenance - improper, company maintenance personnel (contributing factor) - air cond/heating/pressurization - other (contributing factor) - in-flight planning/decision - improper, pilot in command (cause) - physiological condition, pilot in command (cause) - incapacitation, pilot in command (cause) ## Analysis AT AN EN ROUTE STOP, COMPANY MAINTENANCE PERSONNEL OPENED THE FORWARD OVERWING EMERGENCY EXIT TO GAIN ACCESS TO A NAVIGATION LIGHT THAT NEEDED REPAIR. THE FLIGHT ENGINEER SAID THAT DURING PREFLIGHT INSPECTION, THE EMERGENCY EXIT APPEARED TO BE IN PLACE, THOUGH HE DID NOT PHYSICALLY EXAMINE THE EXITS OR LATCHES. LATER, DURING CLIMBOUT, THE FLIGHTCREW WAS UNABLE TO PRESSURIZE THE AIRPLANE. DESPITE OBJECTIONS FROM THE OTHER CREWMEMBERS, THE CAPTAIN ELECTED TO PROCEED WITH THE FLIGHT. THE CREW DONNED THEIR OXYGEN MASKS & A CLIMB WAS CONTINUED TO A CRUISE ALTITUDE AT FL330. SHORTLY AFTER LEVEL OFF, THE CAPTAIN BECAME INCAPACITATED FROM DECOMPRESSION SICKNESS. THE FIRST OFFICER TOOK COMMAND & THE FLIGHT DIVERTED FOR AN EMERGENCY LANDING AT COVINGTON, KY. AFTER FLIGHT, THE EMERGENCY EXIT DOOR WAS FOUND LAYING INSIDE THE AIRPLANE. WHEN CHECKED, THE EXIT DOOR WOULD NOT FIT PROPERLY IN THE FRAME, & THE DOOR LATCHES WOULD NOT ENGAGE THE LATCH PLATES ON THE FRAME, EVEN WHEN THE HANDLE WAS MOVED TO THE LOCKED POSITION. ## Factual narrative On March 15, 1994, at 0727, the flight crew of an American International Airways DC-8-61, N817CK, operating as Connie [Kalitta] Flight 861, made an unscheduled landing at the Greater Cincinnati Airport, Covington, Kentucky, after the captain became incapacitated. The airplane was not damaged. The captain was hospitalized with serious injuries. Visual meteorological conditions prevailed and flight 861 was operated on an instrument flight rules (IFR) flight plan under 14 CFR Part 121. The flight originated in Atlanta, Georgia, with an enroute stop at Charlotte, North Carolina, and then continued to Ypsilanti, Michigan. At Yipsilanti, the flight crew went to breakfast while the cargo was unloaded, and new cargo loaded on the airplane. While on the ground, company maintenance personnel replaced the left wing navigation light on the airplane. Access to the light was gained from the cargo compartment, through the left forward overwing emergency exit, and out onto the wing. The flight engineer (F/E) reported he did two walkarounds on the airplane and the overwing emergency exit appeared in place. He said he did not physically examine the emergency exits or latches. Witnesses reported seeing the airplane takeoff and they thought the left forward overwing exit was not in place as the airplane became airborne. According to flight crew interviews and written statements, the F/E was unable to maintain cabin pressurization after takeoff. The first officer (F/O) and F/E, reported there was no cockpit discussion about staying at a lower altitude until the cause of the lack of pressurization could be determined. The captain made a decision to continue the climb. The flight crew donned their oxygen masks and the flight continued. In the vicinity of FL290 both the F/O and F/E reported the captain was not responding to radio calls, however, the captain indicated via hand signals that he wanted the flight to continue the climb. The flight continued to FL330. While at FL330, the captain's condition continued to deteriorate and the F/O took command of the airplane, and requested a descent. Once the airplane was level at 8000 feet, the flight crew was queried by air traffic if they wanted to declare an emergency. The flight crew declined to declare an emergency and requested to continue the flight to Atlanta, its planned destination. The flight crew then requested to divert to Charlotte. After being informed of the location of the Greater Cincinnati Regional Airport, the flight crew elected to divert there for landing and medical assistance for the captain. The flight landed without incident and the captain was removed and taken to a local hospital. In a written statement made after the accident, the first officer stated: ...I took command when I felt that it was necessary without creating a feeling of mutiny. Since Captain XXXX is a strong willed person and when he is in command he is not to be questioned, I followed his orders.... In a written statement made after the accident, the flight engineer stated: ...It is my opinion that the only way to get the airplane to a lower altitude would be to override the captain by use of physical force. When the captain requested higher altitudes, the first officer and I strongly protested, both verbally and by hand signals. These protests were repeated at least three times during the climb...All protests were disregarded by the captain.... According to FAA Airmen Medical Records, the captain weighed 240 pounds and was 71 inches tall, the first officer was 66 inches tall and weighed 156 pounds, and the flight engineer was 72 inches tall and weighed 190 pounds. Post accident examination of the airplane by FAA personnel from the Louisville Flight Standards District Office found the left forward over wing emergency exit laying on a cargo palette inside the airplane. In a written report, Mr. Jerry Brown stated: ...Company maintenance personnel installed the replacement emergency exit door. After the installation, I observed that on the exterior, the door did not fit flush with the outer surface of the fuselage...Inspection revealed that the door latch slide mechanism was not engaging the latch stop at the top of the door jam, thus preventing the door seal from forming a positive seal. The old door was reinstalled with the same results. Neither door could be pushed fully into the opening far enough to form a flush fit. After an on top-the-wing modification to one of the doors by the maintenance crew, it was reinstalled and a proper installation was attained. After the oxygen system was serviced, I functionally checked the captain's oxygen mask and found it to be operational in all positions. In a telephone interview, Mr. Brown reported that the latches on the emergency exit door would not engage the latch plate on the door frame, even though the handle was extended to the locked position. The overwing emergency exit door would stay in place due to force fit, but it was not locked in place. There was a cargo liner on the emergency exit door that had to be bent out of the way to see if the latches were engaged. He said after to door was worked on by a company mechanic, it fit properly, and the latches engaged. Additionally, Mr. Brown said that the improperly fitting door was recessed against the fuselage and visible when viewed from outside the airplane. The captain's oxygen mask and regulator were removed and tested by the USAF at Brooks Air Force Base. In a written report, they stated, "...Dynamic impedance tests on the regulator, hose and mask system, with proper sealing and use, yielded acceptable values...In summary, test results indicate that the performance of this oxygen regulator is consistent with factory specifications.... Examination of the minimum equipment list revealed restrictions for an unpressurized dispatch. No FAA or company restrictions were found for unpressurized flight when it originated after the dispatch, other than the flight must meet the oxygen requirements of 14 CFR Part 121. The emergency section procedures of the FAA Approved DC-8 Flight Manual contained procedures for a loss of pressurization at altitude and a descent to lower altitudes. No procedure was found for a loss of pressurization at low altitudes and a voluntary climb to high altitude. According to the printout of the flight data recorder, the airplane had achieved an altitude of FL330, 18 minutes after takeoff. The flight stayed at that altitude for approximately 4 minutes and then initiated a descent to 10,000 feet. After 2 minutes at 10,000 feet, the descent continued to 8,000 feet. According to the American International Airways, Inc. instructors guide, initial and recurrent ground training covered the following: 1. GENERAL SITUATION TRAINING g. Rapid Decompression 1) Respiration 2) Hypoxia, hypothermia and hyperventilation 3) Time of useful consciousness 4) Gas expansion/bubble formation 5) Physical phenomena and actual incidents This section is part of a group assigned 4 hours of training. According to company manuals, recurrent training is conducted using 1/2 the programmed number of hours of training. According to company records, the pilot last completed recurrent training which covered, General Emergency Training/Drills, Recurrent, on October 30, 1993. According to Advisory Circular 61-107, dated January 23, 1991, OPERATIONS OF AIRCRAFT AT ALTITUDES ABOVE 25,000 FEET MSL AND/OR MACH NUMBERS (Mmo) GREATER THAN .75: i. When nitrogen is inhaled, it dilutes the air we breathe. While most nitrogen is exhaled from the lungs alon ## Aircraft - Registration: [N817CK](https://openairdocs.org/deregistered/N817CK-2001-07-10), registration cancelled 2001-07-10, S/N 45887 (OpenAirDocs) - Reported make and model: DOUGLAS DC-8-61 - Registry model: [Mcdonnell Douglas DC-8-61](https://openairdocs.org/model/mcdonnell-douglas-dc-8-61) (registry code 302195B) (OpenAirDocs) - Category: Airplane - Serial number: 45887 - Airframe hours: 47167 - Engines: P&W JT3D-3B 17000 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Registered owner: American Intl Airways - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, February 17, 1994, 101 hours before - Departed: YIP, YPSILANTI, MI - Destination: ATL, ATLANTA, GA - Flight plan: IFR - Airport: CVG, Cincinnati, runway 36R, 10,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 20,000 total, 18,000 in this make and model, 18,000 as pilot in command, 149 in the last 90 days, 43 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 14 knots - Visibility: 10 statute miles - Lowest ceiling: 8,500 ft broken - Temperature: 48 °F, dew point 37 °F - Altimeter: 29.00 inHg - Observed at: CVG, 55 nm away ## 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 19940315015819A](https://openairdocs.org/incident/19940315015819A), Mar 15, 1994: Doug DC861, Covington/Cinci, KY. Crew failed to fasten emergency door unnoticed by engineer. Obese pilot suffered decompression incapacitation. 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.