Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Salt Lake City, Utah 84110
Thursday, February 9, 1989 1:00 MST
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 2/9/1989 |
| Event Day of the Week | Thursday |
| Time of Event | 100 |
| Event Time Zone | Mountain Standard Time |
| Event City | SALT LAKE CITY |
| Event State | UTAH |
| Event Country | -- |
| Zipcode of the event site | 84110 |
| Event Date Year | 1989 |
| Event Date Month | 2 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | -- |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Pilot |
| Time of the weather observation | 0 |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | |
| Elevation of weather observation facility | 0 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 0 |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 15 |
| Air Temperature at event time (in degrees celsius) | -7 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 120 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 8 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 30 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 1 |
| Injury Total Minor | -- |
| Injury Total None | 1 |
| Injury Total Serious | -- |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 944 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Feb 9 1989 12:00AM |
| NTSB Notification Time | 500 |
| Fiche Number and/or location -used to find docket information | 39057 |
| Date of most recent change to record | Dec 13 2000 12:28PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N935F |
| NTSB Number | FTW89MA047 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | None |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | MCDONNELL DOUGLAS |
| Aircraft Model | DC-9-32F |
| Aircraft Series Identifier | DC-9-32F |
| Aircraft Serial Number | 47220 |
| Certified Max Gross Weight | 108000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 2 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Jan 13 1989 12:00AM |
| Airframe hours since last inspection | 117 |
| Airframe Hours | 37823 |
| ELT Installed | No |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | -- |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | MCMINNVILLE |
| Aircraft Owner State | OR |
| Aircraft Owner Country | -- |
| Aircraft Owner Zipcode | 97128 |
| Operator is an individual? | No |
| Operator Name | -- |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | -- |
| Operator State | -- |
| Operator Country | -- |
| Operator Zip code | -- |
| Operator Code | EIAA |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Non-scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Cargo |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | KHIF |
| Departure City | OGDEN |
| Departure State | UT |
| Departure Country | |
| Departure Time | 50 |
| Departure Time Zone | MST |
| Destination Same as Local Flt | -- |
| Destination Airport Code | KSKF |
| Destination City | SAN ANTONIO |
| Destination State | TX |
| Destination Country | |
| Specific Phase of Flight | Climb |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Feb 21 2008 4:13PM |
| User who most recently changed record | NTSB\HAMG |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |